Provider Demographics
NPI:1033380647
Name:WHEELER-GOUGH, CYNTHIA LEA (LMSW)
Entity Type:Individual
Prefix:MS
First Name:CYNTHIA
Middle Name:LEA
Last Name:WHEELER-GOUGH
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3333 DEPOSIT DR NE STE 120
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49546-1467
Mailing Address - Country:US
Mailing Address - Phone:616-805-3660
Mailing Address - Fax:
Practice Address - Street 1:118 S GREENVILLE WEST DR STE A
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:MI
Practice Address - Zip Code:48838-3554
Practice Address - Country:US
Practice Address - Phone:616-805-3660
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-23
Last Update Date:2021-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6801087799171W00000X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No171W00000XOther Service ProvidersContractor