Lydia Charlene Wollak
Individual provider Active NPI Other Technician · East Grand Rapids, MI
NPI 1972155034 · NPPES record last updated Jan 18, 2024
Key facts
- NPI
- 1972155034
- Entity type
- Individual (NPI type 1)
- Primary specialty
- Other Technician 247200000X
- Practice address
- 2814 Woodcliff Cir SE
East Grand Rapids, MI 49506-3155 - Phone
- (855) 832-6727
- NPI assigned
- Jul 9, 2019
- Sex
- Female
- Sole proprietor
- No
Organizations & group practices 1
Medicare participation
- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
- Medicare enrollment (NPD)
- Yes
Practice roles
| Organization | Specialty | Status | New patients |
|---|---|---|---|
| Theraplay, Inc. | Current |
Accepting new patients |
Locations
627 Elliott Ave
Grand Haven, MI 49417
Phone (231) 327-4252
2251 East Paris Ave SE
Grand Rapids, MI 49546
Phone (616) 447-7799
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Other Technician | 247200000X | Yes |
Addresses
Primary practice location
2814 Woodcliff Cir SE
East Grand Rapids, MI 49506-3155
Mailing address
154 W 33Rd St
Holland, MI 49423-7106
Other identifiers
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 247200000X | Medicaid | MI |
Other providers in East Grand Rapids, MI
- Margaret Elizabeth Truman
- Joshua Michael Wansten
- West Side Counseling Services
- Jamie Wilcox
- Brockton Willey
- Wonder Wound Care
All providers in East Grand Rapids, MI · Other Technician in Michigan
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Jan 18, 2024. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.