Healthcare Provider Details

I. General information

NPI: 1649790643
Provider Name (Legal Business Name): ELLYN CARPENTER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ELLYN SCHWICKRATH

II. Dates (important events)

Enumeration Date: 06/21/2017
Last Update Date: 08/05/2026
Certification Date: 08/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1113 W SUPERIOR ST
WAYLAND MI
49348-1228
US

IV. Provider business mailing address

1113 W SUPERIOR ST
WAYLAND MI
49348-1228
US

V. Phone/Fax

Practice location:
  • Phone: 616-252-6711
  • Fax:
Mailing address:
  • Phone: 616-252-6711
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number6801104219
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: