Provider Demographics
NPI:1063754794
Name:WENGLIKOWSKI, LORI GAYLE (LMSW)
Entity type:Individual
Prefix:
First Name:LORI
Middle Name:GAYLE
Last Name:WENGLIKOWSKI
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:412 CENTURY LN
Mailing Address - Street 2:
Mailing Address - City:HOLLAND
Mailing Address - State:MI
Mailing Address - Zip Code:49423-4285
Mailing Address - Country:US
Mailing Address - Phone:616-396-2301
Mailing Address - Fax:616-396-8070
Practice Address - Street 1:412 CENTURY LN
Practice Address - Street 2:
Practice Address - City:HOLLAND
Practice Address - State:MI
Practice Address - Zip Code:49423-4285
Practice Address - Country:US
Practice Address - Phone:616-396-2301
Practice Address - Fax:616-396-8070
Is Sole Proprietor?:No
Enumeration Date:2013-03-20
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI1-04700101YA0400X
MI6801097918101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)