Provider Demographics
NPI:1710390372
Name:WICKSALL, LAURA MEEKER (LMSW)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:MEEKER
Last Name:WICKSALL
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:LAURA
Other - Middle Name:
Other - Last Name:MEEKER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
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:49506-1723
Mailing Address - Country:US
Mailing Address - Phone:
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:49506-1723
Practice Address - Country:US
Practice Address - Phone:231-499-1063
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-06-11
Last Update Date:2018-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI101YA0400X
101YP2500X
MI6801095775104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional