Healthcare Provider Details

I. General information

NPI: 1902997224
Provider Name (Legal Business Name): WEDGWOOD CHRISTIAN SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/28/2006
Last Update Date: 11/04/2024
Certification Date: 11/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3300 36TH ST SE
GRAND RAPIDS MI
49512-2810
US

IV. Provider business mailing address

3300 36TH ST SE
GRAND RAPIDS MI
49512-2810
US

V. Phone/Fax

Practice location:
  • Phone: 616-942-2110
  • Fax: 616-942-0589
Mailing address:
  • Phone: 616-942-2110
  • Fax: 616-942-0589

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code322D00000X
TaxonomyEmotionally Disturbed Childrens' Residential Treatment Facility
License NumberCI410201226
License Number StateMI
# 3
Primary TaxonomyN
Taxonomy Code322D00000X
TaxonomyEmotionally Disturbed Childrens' Residential Treatment Facility
License NumberCI410201359
License Number StateMI
# 4
Primary TaxonomyN
Taxonomy Code322D00000X
TaxonomyEmotionally Disturbed Childrens' Residential Treatment Facility
License NumberCI410201082
License Number StateMI
# 5
Primary TaxonomyN
Taxonomy Code322D00000X
TaxonomyEmotionally Disturbed Childrens' Residential Treatment Facility
License NumberCICI410201003
License Number StateMI
# 6
Primary TaxonomyN
Taxonomy Code322D00000X
TaxonomyEmotionally Disturbed Childrens' Residential Treatment Facility
License NumberCI410201501
License Number StateMI
# 7
Primary TaxonomyN
Taxonomy Code3245S0500X
TaxonomyChildren's Substance Abuse Rehabilitation Facility
License NumberCI410201502
License Number StateMI
# 8
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: DANIEL T GOWDY
Title or Position: CEO/PRESIDENT
Credential: ED D, CFRE
Phone: 616-942-2110