Basic Information
| Provider Information | |||||||||
| NPI: | 1275092348 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WILSON-GUZAK | ||||||||
| FirstName: | JODI | ||||||||
| MiddleName: | RENE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | LPC | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | WILSON | ||||||||
| OtherFirstName: | JODI | ||||||||
| OtherMiddleName: | R | ||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 6445 AMBER LN | ||||||||
| Address2: | |||||||||
| City: | GRAND BLANC | ||||||||
| State: | MI | ||||||||
| PostalCode: | 484397835 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7347518932 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1100 TORREY RD STE 100 | ||||||||
| Address2: | |||||||||
| City: | FENTON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 484303327 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8109447180 | ||||||||
| FaxNumber: | 8102151334 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/18/2019 | ||||||||
| LastUpdateDate: | 03/18/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | 6401008556 | MI | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
No ID Information.