Healthcare Provider Details

I. General information

NPI: 1598810137
Provider Name (Legal Business Name): WILSON AND WYNN INTERVENTIONS, PLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/24/2007
Last Update Date: 02/06/2023
Certification Date: 02/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4519 CASCADE RD SE STE 6
GRAND RAPIDS MI
49546-8319
US

IV. Provider business mailing address

10843 CRAWFORD LAKE TRL
CEDAR SPRINGS MI
49319-8771
US

V. Phone/Fax

Practice location:
  • Phone: 616-647-3460
  • Fax:
Mailing address:
  • Phone: 616-647-3460
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number6301008405
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number6301012332
License Number StateMI
# 3
Primary TaxonomyN
Taxonomy Code103TM1800X
TaxonomyIntellectual & Developmental Disabilities Psychologist
License Number6301012332
License Number StateMI
# 4
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6801083017
License Number StateMI
# 5
Primary TaxonomyY
Taxonomy Code103TM1800X
TaxonomyIntellectual & Developmental Disabilities Psychologist
License Number6301008405
License Number StateMI

VIII. Authorized Official

Name: SANDRA JEAN WYNN-STELT
Title or Position: CO-OWNER
Credential:
Phone: 616-647-3460