Provider Demographics
NPI:1265920342
Name:WIERSMA, MICHAEL JOHN (LPC)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:JOHN
Last Name:WIERSMA
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11479 92ND AVE
Mailing Address - Street 2:
Mailing Address - City:ALLENDALE
Mailing Address - State:MI
Mailing Address - Zip Code:49401-7511
Mailing Address - Country:US
Mailing Address - Phone:616-214-0356
Mailing Address - Fax:
Practice Address - Street 1:7791 BYRON CENTER AVE SW
Practice Address - Street 2:
Practice Address - City:BYRON CENTER
Practice Address - State:MI
Practice Address - Zip Code:49315-8412
Practice Address - Country:US
Practice Address - Phone:800-453-7733
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-25
Last Update Date:2020-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401016613101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional