Healthcare Provider Details

I. General information

NPI: 1750740312
Provider Name (Legal Business Name): MICHAEL WILKES
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/11/2016
Last Update Date: 02/11/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3330 CLAYSTONE ST SE
GRAND RAPIDS MI
49546-7738
US

IV. Provider business mailing address

812 PINNACLE RUN DR SE
GRAND RAPIDS MI
49546-8342
US

V. Phone/Fax

Practice location:
  • Phone: 616-949-7460
  • Fax:
Mailing address:
  • Phone: 313-505-4793
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number6401015302
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number4101006677
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: