Basic Information
| Provider Information | |||||||||
| NPI: | 1992056725 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WHEELER | ||||||||
| FirstName: | JOSEPH | ||||||||
| MiddleName: | BROOKS | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PH.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 601 JOHN ST | ||||||||
| Address2: | SUITE M-124 | ||||||||
| City: | KALAMAZOO | ||||||||
| State: | MI | ||||||||
| PostalCode: | 490075341 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2693417500 | ||||||||
| FaxNumber: | 2693417540 | ||||||||
| Practice Location | |||||||||
| Address1: | 601 JOHN ST | ||||||||
| Address2: | SUITE M-124 | ||||||||
| City: | KALAMAZOO | ||||||||
| State: | MI | ||||||||
| PostalCode: | 490075341 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2693417500 | ||||||||
| FaxNumber: | 2693417540 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/19/2012 | ||||||||
| LastUpdateDate: | 01/08/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/08/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103G00000X | 6301015978 | MI | N | Behavioral Health & Social Service Providers | Clinical Neuropsychologist | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 103TC0700X | 6301015978 | MI | Y | Behavioral Health & Social Service Providers | Psychologist | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 1992056725 | 05 | MI | MEDICAID |