Provider Demographics
NPI:1588317119
Name:WISDOM CENTER LLC
Entity type:Organization
Organization Name:WISDOM CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:SAMUEL
Authorized Official - Middle Name:
Authorized Official - Last Name:JONES
Authorized Official - Suffix:
Authorized Official - Credentials:MA LPC
Authorized Official - Phone:616-212-8943
Mailing Address - Street 1:5180 KALAMAZOO AVE SE STE 2
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49508-4817
Mailing Address - Country:US
Mailing Address - Phone:616-419-8103
Mailing Address - Fax:
Practice Address - Street 1:5180 KALAMAZOO AVE SE STE 2
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49508-4817
Practice Address - Country:US
Practice Address - Phone:616-419-8103
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-02-02
Last Update Date:2022-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)