MEDICARE: MYSTIC ESTRELLA WILDE BT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	106S00000X	Behavior Technician

General Provider Information

NPI Number	:	1114804481
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MYSTIC ESTRELLA WILDE BT

Provider Business Mailing Address
First Line	:	625 KENMOOR AVE SE STE 301
Second Line	:
City	:	GRAND RAPIDS
State	:	MI
Zip	:	49546-2395
Country	:	US
Telephone Number	:	231-519-8300
Fax Number	:

Provider Business Practice Location Address
First Line	:	239 S ENSLEY ST # 2285280
Second Line	:
City	:	HOWARD CITY
State	:	MI
Zip	:	49329-8656
Country	:	US
Telephone Number	:	231-519-8300
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/19/2025
Last Update Date	:	08/19/2025

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