Provider Demographics
NPI:1790135374
Name:WEINER, MISTY
Entity Type:Individual
Prefix:
First Name:MISTY
Middle Name:
Last Name:WEINER
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 1:7681 WALNUT AVE
Mailing Address - Street 2:
Mailing Address - City:JENISON
Mailing Address - State:MI
Mailing Address - Zip Code:49428-7941
Mailing Address - Country:US
Mailing Address - Phone:989-330-3455
Mailing Address - Fax:
Practice Address - Street 1:4873 BURRWOOD ST SE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49546-3769
Practice Address - Country:US
Practice Address - Phone:616-900-4999
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-15
Last Update Date:2022-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician