Provider Demographics
NPI:1669815650
Name:LAINA WIRGAU
Entity Type:Organization
Organization Name:LAINA WIRGAU
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:THERAPIST
Authorized Official - Prefix:MISS
Authorized Official - First Name:LAINA
Authorized Official - Middle Name:
Authorized Official - Last Name:WIRGAU
Authorized Official - Suffix:
Authorized Official - Credentials:LLMSW
Authorized Official - Phone:616-558-5531
Mailing Address - Street 1:1115 BALL AVE NE BLDG A
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49505-5904
Mailing Address - Country:US
Mailing Address - Phone:616-558-5531
Mailing Address - Fax:
Practice Address - Street 1:6157 WOODFIELD PL SE APT 9
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49548-8585
Practice Address - Country:US
Practice Address - Phone:616-558-5531
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-04-10
Last Update Date:2013-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI680194489251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health