Provider Demographics
NPI:1467890152
Name:WICHTERMAN, MELISSA
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:
Last Name:WICHTERMAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2828 KRAFT AVE SE STE 186
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49512-2076
Mailing Address - Country:US
Mailing Address - Phone:616-949-9550
Mailing Address - Fax:269-979-7766
Practice Address - Street 1:2828 KRAFT AVE SE STE 186
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49512-2076
Practice Address - Country:US
Practice Address - Phone:616-949-9550
Practice Address - Fax:616-949-9551
Is Sole Proprietor?:No
Enumeration Date:2013-06-05
Last Update Date:2023-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401012129101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI6401012129OtherLICENSE #