Healthcare Provider Details

I. General information

NPI: 1033398581
Provider Name (Legal Business Name): SANDRA JEAN WYNN-STELT MA LLP BCBA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/01/2007
Last Update Date: 04/17/2020
Certification Date: 04/17/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

680 3 MILE RD NW SUITE C
GRAND RAPIDS MI
49544-8218
US

IV. Provider business mailing address

680 3 MILE RD NW SUITE C
GRAND RAPIDS MI
49544-8218
US

V. Phone/Fax

Practice location:
  • Phone: 616-647-3460
  • Fax: 616-647-3467
Mailing address:
  • Phone: 616-647-3460
  • Fax: 616-647-3467

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-14-15612
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code103TB0200X
TaxonomyCognitive & Behavioral Psychologist
License Number6301008405
License Number StateMI
# 3
Primary TaxonomyY
Taxonomy Code103TM1800X
TaxonomyIntellectual & Developmental Disabilities Psychologist
License Number6301008405
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: