Provider Demographics
NPI:1558453142
Name:WIERDA, AMY (MSW)
Entity Type:Individual
Prefix:MS
First Name:AMY
Middle Name:
Last Name:WIERDA
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5060 CASCADE RD SE
Mailing Address - Street 2:SUITE D
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49546
Mailing Address - Country:US
Mailing Address - Phone:616-454-2911
Mailing Address - Fax:616-454-1126
Practice Address - Street 1:5060 CASCADE RD SE
Practice Address - Street 2:SUITE D
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49546
Practice Address - Country:US
Practice Address - Phone:616-454-2911
Practice Address - Fax:616-454-1126
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-29
Last Update Date:2009-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010653511041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical