Healthcare Provider Details

I. General information

NPI: 1487187050
Provider Name (Legal Business Name): ALICIA WILDER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/10/2017
Last Update Date: 01/11/2022
Certification Date: 10/20/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1324 LAKE DR SE STE 8
GRAND RAPIDS MI
49506-1673
US

IV. Provider business mailing address

1324 LAKE DR SE STE 8
GRAND RAPIDS MI
49506-1673
US

V. Phone/Fax

Practice location:
  • Phone: 616-929-0745
  • Fax:
Mailing address:
  • Phone: 616-929-0745
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6801094425
License Number StateMI

VIII. Authorized Official

Name: ALICIA D SCHAULAND
Title or Position: PSYCHOTHERAPIST
Credential:
Phone: 616-822-9733