Healthcare Provider Details

I. General information

NPI: 1902011109
Provider Name (Legal Business Name): DENISE WUNDERLICH LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/11/2007
Last Update Date: 09/29/2022
Certification Date: 09/28/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2150 W. SOUTH AIRPORT RD, SUITE C
TRAVERSE CITY MI
49684-1387
US

IV. Provider business mailing address

PO BOX 475
EMPIRE MI
49630-0475
US

V. Phone/Fax

Practice location:
  • Phone: 248-217-2353
  • Fax:
Mailing address:
  • Phone: 248-217-2353
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number6401000759
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6801058736
License Number StateMI
# 3
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number6401000759
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: