Provider Demographics
NPI:1235560152
Name:WISZCZUR, ERIC
Entity Type:Individual
Prefix:
First Name:ERIC
Middle Name:
Last Name:WISZCZUR
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3733 PIUTE DR SW
Mailing Address - Street 2:
Mailing Address - City:GRANDVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:49418-1950
Mailing Address - Country:US
Mailing Address - Phone:616-510-0511
Mailing Address - Fax:
Practice Address - Street 1:1843 R W BERENDS DR SW
Practice Address - Street 2:
Practice Address - City:WYOMING
Practice Address - State:MI
Practice Address - Zip Code:49519-4955
Practice Address - Country:US
Practice Address - Phone:800-693-1916
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-12-03
Last Update Date:2023-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401013963101Y00000X
101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health