Provider Demographics
NPI:1174773378
Name:WILEY, ANITA (LCPC)
Entity type:Individual
Prefix:
First Name:ANITA
Middle Name:
Last Name:WILEY
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:616 CHARLES ST STE 103
Mailing Address - Street 2:
Mailing Address - City:LA PLATA
Mailing Address - State:MD
Mailing Address - Zip Code:20646-5938
Mailing Address - Country:US
Mailing Address - Phone:301-653-9587
Mailing Address - Fax:301-653-9587
Practice Address - Street 1:616 CHARLES ST STE 103
Practice Address - Street 2:
Practice Address - City:LA PLATA
Practice Address - State:MD
Practice Address - Zip Code:20646-5938
Practice Address - Country:US
Practice Address - Phone:301-653-9587
Practice Address - Fax:301-653-9587
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-24
Last Update Date:2024-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLC5129101YP1600X, 101YP2500X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoral
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD58956180Medicaid
MD58956180Medicaid