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NPI Code Detail

MEDICARE: JOHN PHILLIP WAKE

MEDICARE: JOHN PHILLIP WAKE
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
1106S00000XBehavior Technician

General Provider Information

NPI Number : 1972432789
Entity Type Code : Individual
Provider Name (Legal Business Name) : JOHN PHILLIP WAKE
Provider Business Mailing Address
First Line : 4234 CASCADE RD SE STE 3
Second Line :
City : GRAND RAPIDS
State : MI
Zip : 49546-8384
Country : US
Telephone Number : 888-614-4144
Fax Number :
Provider Business Practice Location Address
First Line : 4234 CASCADE RD SE STE 3
Second Line :
City : GRAND RAPIDS
State : MI
Zip : 49546-8384
Country : US
Telephone Number : 888-614-4144
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 05/18/2026
Last Update Date : 06/11/2026

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Directions to “ JOHN PHILLIP WAKE ” Practice Location

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