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General NPI Number Information
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NPI Number | 1750414827
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Entity Type | Organization
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Legal Business Name | WEDGWOOD CHRISTAIN SERVICES
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Dates
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Enumeration Date | 03/14/2007
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 3300 36TH ST SE
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City | GRAND RAPIDS
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State | MI
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Zip | 49512-2810
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Country | US
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Telephone | 616-559-5835
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Fax | 616-281-6448
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Provider Business Mailing Address
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Address Line | 8117 CRESTVIEW AVE
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City | JENISON
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State | MI
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Zip | 49428-9124
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Country | US
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Telephone | 616-706-0204
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Fax |
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Authorized Official
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Title or Position | THERAPIST
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Name | MR. ROBERT GERARD JOHNSON SR.
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Credential | LPC
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Telephone | 616-559-5835
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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 |
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License Number State |
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