Basic Information
| Provider Information | |||||||||
| NPI: | 1902997224 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | WEDGWOOD CHRISTIAN SERVICES | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 3300 36TH ST SE | ||||||||
| Address2: | |||||||||
| City: | GRAND RAPIDS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 495122810 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6169422110 | ||||||||
| FaxNumber: | 6169420589 | ||||||||
| Practice Location | |||||||||
| Address1: | 3300 36TH ST SE | ||||||||
| Address2: | |||||||||
| City: | GRAND RAPIDS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 495122810 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6169422110 | ||||||||
| FaxNumber: | 6169420589 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/28/2006 | ||||||||
| LastUpdateDate: | 03/24/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | GOWDY | ||||||||
| AuthorizedOfficialFirstName: | DANIEL | ||||||||
| AuthorizedOfficialMiddleName: | T | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO/PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 6169422110 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | ED D, CFRE | ||||||||
| NPICertificationDate: | 03/24/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR0405X | N | Ambulatory Health Care Facilities | Clinic/Center | Rehabilitation, Substance Use Disorder | 322D00000X | CI410201226 | MI | N | Residential Treatment Facilities | Residential Treatment Facility, Emotionally Disturbed Children | 322D00000X | CI410201359 | MI | N | Residential Treatment Facilities | Residential Treatment Facility, Emotionally Disturbed Children | 322D00000X | CI410201082 | MI | N | Residential Treatment Facilities | Residential Treatment Facility, Emotionally Disturbed Children | 322D00000X | CICI410201003 | MI | N | Residential Treatment Facilities | Residential Treatment Facility, Emotionally Disturbed Children | 322D00000X | CI410201501 | MI | N | Residential Treatment Facilities | Residential Treatment Facility, Emotionally Disturbed Children | 3245S0500X | CI410201502 | MI | N | Residential Treatment Facilities | Substance Abuse Rehabilitation Facility | Substance Abuse Treatment, Children | 261QM1300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Multi-Specialty |
No ID Information.