Provider Demographics
NPI:1215047667
Name:WEDGWOOD CHRISTIAN SERVICES
Entity type:Organization
Organization Name:WEDGWOOD CHRISTIAN SERVICES
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:T
Authorized Official - Last Name:GOWDY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:616-942-2110
Mailing Address - Street 1:3300 36TH ST SE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49512-2810
Mailing Address - Country:US
Mailing Address - Phone:616-942-2110
Mailing Address - Fax:616-942-0589
Practice Address - Street 1:3300 36TH ST SE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49512-2810
Practice Address - Country:US
Practice Address - Phone:616-942-2110
Practice Address - Fax:616-942-0589
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-30
Last Update Date:2023-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI251S00000X, 2084P0800X, 103TC0700X
MI280070101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
Yes251S00000XAgenciesCommunity/Behavioral HealthGroup - Multi-Specialty
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1464983Medicaid
MIMI7923Medicare PIN
MI0N98490Medicare PIN
MI7509105650OtherBCBS
MI7509125650OtherBCBS
MI7509135650OtherBCBS