Basic Information
| Provider Information | |||||||||
| NPI: | 1619111036 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WING | ||||||||
| FirstName: | TERRY | ||||||||
| MiddleName: | LEE | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LMSW (MACRO) | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1629 PHILADELPHIA AVE SE | ||||||||
| Address2: | |||||||||
| City: | GRAND RAPIDS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 495072251 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6162411736 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 277 NORTH ST | ||||||||
| Address2: | |||||||||
| City: | ALLEGAN | ||||||||
| State: | MI | ||||||||
| PostalCode: | 490101138 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2696735092 | ||||||||
| FaxNumber: | 2696864601 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/29/2009 | ||||||||
| LastUpdateDate: | 04/29/2009 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X | 6801086799 | MI | Y | Other Service Providers | Case Manager/Care Coordinator |
No ID Information.