Healthcare Provider Details

I. General information

NPI: 1871192120
Provider Name (Legal Business Name): KATELYN WYSOCKI MA, LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/19/2020
Last Update Date: 04/30/2025
Certification Date: 04/30/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3450 ALPINE AVE NW STE 207
GRAND RAPIDS MI
49544-1666
US

IV. Provider business mailing address

PO BOX 141541
GRAND RAPIDS MI
49514-1541
US

V. Phone/Fax

Practice location:
  • Phone: 616-215-0588
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number6401017994
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: