Provider Demographics
NPI:1750414827
Name:WEDGWOOD CHRISTAIN SERVICES
Entity type:Organization
Organization Name:WEDGWOOD CHRISTAIN SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:THERAPIST
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:GERARD
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:SR
Authorized Official - Credentials:LPC
Authorized Official - Phone:616-559-5835
Mailing Address - Street 1:8117 CRESTVIEW AVE
Mailing Address - Street 2:
Mailing Address - City:JENISON
Mailing Address - State:MI
Mailing Address - Zip Code:49428-9124
Mailing Address - Country:US
Mailing Address - Phone:616-706-0204
Mailing Address - Fax:
Practice Address - Street 1:3300 36TH ST SE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49512-2810
Practice Address - Country:US
Practice Address - Phone:616-559-5835
Practice Address - Fax:616-281-6448
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-14
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI100594OtherADDICTION COUNSELOR
MI6401008579OtherPROFESSIONAL COUNSELOR