Basic Information
| Provider Information | |||||||||
| NPI: | 1740351014 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GORNICK-MAYCROFT | ||||||||
| FirstName: | WENDY | ||||||||
| MiddleName: | LOU | ||||||||
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| Credential: | MA, LPC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 221 RIVERFRONT ST APT 5 | ||||||||
| Address2: | |||||||||
| City: | SPRING LAKE | ||||||||
| State: | MI | ||||||||
| PostalCode: | 494562081 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9898022263 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 640 3 MILE RD NW STE G | ||||||||
| Address2: | |||||||||
| City: | GRAND RAPIDS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 495448209 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8006931916 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/10/2006 | ||||||||
| LastUpdateDate: | 08/03/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 08/03/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | N | Behavioral Health & Social Service Providers | Counselor | 101YP2500X | 6401012338 | MI | N | Behavioral Health & Social Service Providers | Counselor | Professional | 101Y00000X | 6401012338 | Y | Behavioral Health & Social Service Providers | Counselor |
No ID Information.