Provider Demographics
NPI:1083377980
Name:WISDOM, BRYAN R (LLMFT)
Entity Type:Individual
Prefix:
First Name:BRYAN
Middle Name:R
Last Name:WISDOM
Suffix:
Gender:M
Credentials:LLMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:928 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:ELKHART
Mailing Address - State:IN
Mailing Address - Zip Code:46514-2736
Mailing Address - Country:US
Mailing Address - Phone:859-402-3795
Mailing Address - Fax:
Practice Address - Street 1:233 FULTON ST E STE 28
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-3262
Practice Address - Country:US
Practice Address - Phone:616-228-9244
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-18
Last Update Date:2021-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4151001031106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist