Healthcare Provider Details

I. General information

NPI: 1740351014
Provider Name (Legal Business Name): WENDY LOU GORNICK-MAYCROFT MA, LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/10/2006
Last Update Date: 08/03/2022
Certification Date: 08/03/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

640 3 MILE RD NW STE G
GRAND RAPIDS MI
49544-8209
US

IV. Provider business mailing address

221 RIVERFRONT ST APT 5
SPRING LAKE MI
49456-2081
US

V. Phone/Fax

Practice location:
  • Phone: 800-693-1916
  • Fax:
Mailing address:
  • Phone: 989-802-2263
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number6401012338
License Number StateMI
# 3
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number6401012338
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: