Provider Demographics
NPI:1609376425
Name:WRZESINSKI, ALICA M
Entity Type:Individual
Prefix:
First Name:ALICA
Middle Name:M
Last Name:WRZESINSKI
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 1:56345 COUNTY ROAD 384
Mailing Address - Street 2:
Mailing Address - City:GRAND JUNCTION
Mailing Address - State:MI
Mailing Address - Zip Code:49056-9753
Mailing Address - Country:US
Mailing Address - Phone:269-434-6959
Mailing Address - Fax:
Practice Address - Street 1:56345 COUNTY ROAD 384
Practice Address - Street 2:
Practice Address - City:GRAND JUNCTION
Practice Address - State:MI
Practice Address - Zip Code:49056-9753
Practice Address - Country:US
Practice Address - Phone:269-434-6959
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-19
Last Update Date:2018-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIAF800238276253J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253J00000XAgenciesFoster Care Agency
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIAF800238276Medicaid