Provider Demographics
NPI:1740351014
Name:GORNICK-MAYCROFT, WENDY LOU (MA, LPC)
Entity type:Individual
Prefix:
First Name:WENDY
Middle Name:LOU
Last Name:GORNICK-MAYCROFT
Suffix:
Gender:F
Credentials:MA, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:221 RIVERFRONT ST APT 5
Mailing Address - Street 2:
Mailing Address - City:SPRING LAKE
Mailing Address - State:MI
Mailing Address - Zip Code:49456-2081
Mailing Address - Country:US
Mailing Address - Phone:989-802-2263
Mailing Address - Fax:
Practice Address - Street 1:640 3 MILE RD NW STE G
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49544-8209
Practice Address - Country:US
Practice Address - Phone:800-693-1916
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-10
Last Update Date:2022-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X
MI6401012338101YP2500X
6401012338101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL2035727OtherCIGNA
IL12400847OtherMULTIPLAN
IL9419159OtherPHCS
IL08932022OtherBCBS- ILLINOIS