MEDICARE: LUKE WOLTHUIS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor	6451023193	MI

General Provider Information

NPI Number	:	1669259750
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LUKE WOLTHUIS

Provider Business Mailing Address
First Line	:	750 GRACELAND ST NE
Second Line	:
City	:	GRAND RAPIDS
State	:	MI
Zip	:	49505-4258
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	678 FRONT AVE NW
Second Line	:
City	:	GRAND RAPIDS
State	:	MI
Zip	:	49504-5325
Country	:	US
Telephone Number	:	616-916-3711
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/12/2023
Last Update Date	:	10/06/2023

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