Healthcare Provider Details

I. General information

NPI: 1275229270
Provider Name (Legal Business Name): WANDA L COUCH LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/12/2023
Last Update Date: 04/12/2023
Certification Date: 04/12/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2305 EAST PARIS AVE SE
GRAND RAPIDS MI
49546-2426
US

IV. Provider business mailing address

2032 FRANCIS AVE SE
GRAND RAPIDS MI
49507-3015
US

V. Phone/Fax

Practice location:
  • Phone: 616-541-0433
  • Fax:
Mailing address:
  • Phone: 616-299-1648
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number6401019041
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: