Provider Demographics
NPI:1205893815
Name:WIECZOREK, ERIN E (LMSW)
Entity type:Individual
Prefix:
First Name:ERIN
Middle Name:E
Last Name:WIECZOREK
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2100 RAYBROOK ST. SE
Mailing Address - Street 2:STE 203
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49546
Mailing Address - Country:US
Mailing Address - Phone:616-954-1558
Mailing Address - Fax:616-954-3400
Practice Address - Street 1:2100 RAYBROOK ST. SE
Practice Address - Street 2:STE 203
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49546
Practice Address - Country:US
Practice Address - Phone:616-956-9440
Practice Address - Fax:616-954-1520
Is Sole Proprietor?:No
Enumeration Date:2006-04-27
Last Update Date:2022-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
104100000X
MI6802082638104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI774508891Medicaid