Healthcare Provider Details

I. General information

NPI: 1497223424
Provider Name (Legal Business Name): LAURA MEEKER WICKSALL THERAPY PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/07/2018
Last Update Date: 11/07/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1430 ROBINSON RD SE STE 206
GRAND RAPIDS MI
49506-1780
US

IV. Provider business mailing address

1430 ROBINSON RD SE STE 206
GRAND RAPIDS MI
49506-1780
US

V. Phone/Fax

Practice location:
  • Phone:
  • Fax:
Mailing address:
  • Phone: 616-438-6054
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name: LAURA MEEKER WICKSALL
Title or Position: OWNER/THERAPIST
Credential:
Phone: 231-499-1063