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General NPI Number Information
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NPI Number | 1518404128
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Entity Type | Organization
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Legal Business Name | AUTHENTIC LIFE COUNSELING AND WELLNESS, PLLC
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Dates
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Enumeration Date | 01/21/2017
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Last Update Date | 01/21/2017
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Provider Practice Location Address
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Address Line | 1200 W ELEVENTH ST SUITE 218
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City | TRAVERSE CITY
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State | MI
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Zip | 49684-3287
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Country | US
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Telephone | 231-714-0292
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Fax |
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Provider Business Mailing Address
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Address Line | 13554 S HIGH POINT DR
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City | TRAVERSE CITY
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State | MI
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Zip | 49684-5534
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Country | US
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Telephone | 231-714-0292
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | KRISTINA WIERSEMA
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Credential | LMSW
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Telephone | 231-714-0292
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 104100000X
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Taxonomy Name | Social Worker
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License Number | 6801093573
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License Number State | MI
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