Provider Demographics
NPI:1497223424
Name:LAURA MEEKER WICKSALL THERAPY PLLC
Entity Type:Organization
Organization Name:LAURA MEEKER WICKSALL THERAPY PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:LAURA
Authorized Official - Middle Name:MEEKER
Authorized Official - Last Name:WICKSALL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:231-499-1063
Mailing Address - Street 1:1430 ROBINSON RD SE STE 206
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49506-1780
Mailing Address - Country:US
Mailing Address - Phone:616-438-6054
Mailing Address - Fax:
Practice Address - Street 1:1430 ROBINSON RD SE STE 206
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49506-1780
Practice Address - Country:US
Practice Address - Phone:
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-11-07
Last Update Date:2018-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1710390372OtherINDIVIDUAL