Healthcare Provider Details

I. General information

NPI: 1346499639
Provider Name (Legal Business Name): MS. JODY LYNN WILFONG
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: JODY LYNN PRIESTLEY MT-BC,NMT

II. Dates (important events)

Enumeration Date: 09/11/2008
Last Update Date: 09/11/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15283 LONGFELLOW DR
BYRON MI
48418-8846
US

IV. Provider business mailing address

15283 LONGFELLOW DR
BYRON MI
48418-8846
US

V. Phone/Fax

Practice location:
  • Phone: 810-266-4045
  • Fax:
Mailing address:
  • Phone: 810-266-4045
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225A00000X
TaxonomyMusic Therapist
License Number06257
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: