Provider Demographics
NPI:1194531459
Name:WIERENGA, ELLIOT
Entity type:Individual
Prefix:
First Name:ELLIOT
Middle Name:
Last Name:WIERENGA
Suffix:
Gender:X
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:29226 ORCHARD LAKE RD STE 290
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48334-3062
Mailing Address - Country:US
Mailing Address - Phone:231-412-1582
Mailing Address - Fax:
Practice Address - Street 1:29226 ORCHARD LAKE RD STE 290
Practice Address - Street 2:
Practice Address - City:FARMINGTON HILLS
Practice Address - State:MI
Practice Address - Zip Code:48334-3062
Practice Address - Country:US
Practice Address - Phone:231-412-1582
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-12-10
Last Update Date:2024-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician