Provider Demographics
NPI:1275092348
Name:WILSON-GUZAK, JODI RENE (LPC)
Entity Type:Individual
Prefix:
First Name:JODI
Middle Name:RENE
Last Name:WILSON-GUZAK
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:JODI
Other - Middle Name:R
Other - Last Name:WILSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:6445 AMBER LN
Mailing Address - Street 2:
Mailing Address - City:GRAND BLANC
Mailing Address - State:MI
Mailing Address - Zip Code:48439-7835
Mailing Address - Country:US
Mailing Address - Phone:734-751-8932
Mailing Address - Fax:
Practice Address - Street 1:1100 TORREY RD STE 100
Practice Address - Street 2:
Practice Address - City:FENTON
Practice Address - State:MI
Practice Address - Zip Code:48430-3327
Practice Address - Country:US
Practice Address - Phone:810-944-7180
Practice Address - Fax:810-215-1334
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-18
Last Update Date:2019-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401008556101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional