Basic Information
| Provider Information | |||||||||
| NPI: | 1013281450 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | VAN WYCK | ||||||||
| FirstName: | ROSANNA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | LLPC | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | SUTTON | ||||||||
| OtherFirstName: | ROSANNA | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | LLPC | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 920 DIANA ST | ||||||||
| Address2: | |||||||||
| City: | LUDINGTON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 494311987 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2318456294 | ||||||||
| FaxNumber: | 2318457095 | ||||||||
| Practice Location | |||||||||
| Address1: | 920 DIANA ST | ||||||||
| Address2: | |||||||||
| City: | LUDINGTON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 494311987 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2318456294 | ||||||||
| FaxNumber: | 2318457095 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/02/2012 | ||||||||
| LastUpdateDate: | 09/17/2012 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | 6401012777 | MI | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.