Provider Demographics
NPI:1174952154
Name:WIMBLEY, QIANA
Entity type:Individual
Prefix:MS
First Name:QIANA
Middle Name:
Last Name:WIMBLEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1576 SOUTHFIELD RD
Mailing Address - Street 2:
Mailing Address - City:BIRMINGHAM
Mailing Address - State:MI
Mailing Address - Zip Code:48009-3004
Mailing Address - Country:US
Mailing Address - Phone:313-676-7278
Mailing Address - Fax:
Practice Address - Street 1:1576 SOUTHFIELD RD
Practice Address - Street 2:
Practice Address - City:BIRMINGHAM
Practice Address - State:MI
Practice Address - Zip Code:48009-3004
Practice Address - Country:US
Practice Address - Phone:313-676-7278
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-11
Last Update Date:2013-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401012951101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor