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General NPI Number Information
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NPI Number | 1669815650
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Entity Type | Organization
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Legal Business Name | LAINA WIRGAU
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Dates
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Enumeration Date | 04/10/2013
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Last Update Date | 04/26/2013
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Provider Practice Location Address
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Address Line | 6157 WOODFIELD PL SE APT 9
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City | GRAND RAPIDS
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State | MI
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Zip | 49548-8585
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Country | US
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Telephone | 616-558-5531
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Fax |
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Provider Business Mailing Address
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Address Line | 1115 BALL AVE NE BLDG A
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City | GRAND RAPIDS
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State | MI
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Zip | 49505-5904
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Country | US
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Telephone | 616-558-5531
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Fax |
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Authorized Official
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Title or Position | THERAPIST
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Name | MISS LAINA WIRGAU
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Credential | LLMSW
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Telephone | 616-558-5531
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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License Number | 680194489
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License Number State | MI
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