MEDICARE: MR. RONNIE LEE WILKES JR. LPC, CRC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101Y00000X	Counselor	00099107	NC
2	101YM0800X	Mental Health Counselor	6970	NC

General Provider Information

NPI Number	:	1639326549
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. RONNIE LEE WILKES JR. LPC, CRC

Provider Business Mailing Address
First Line	:	140 CHARLESTOWNE CIR
Second Line	:
City	:	WINSTON SALEM
State	:	NC
Zip	:	27103-5717
Country	:	US
Telephone Number	:	336-416-8275
Fax Number	:

Provider Business Practice Location Address
First Line	:	500 W NORTHWEST BLVD
Second Line	:
City	:	WINSTON SALEM
State	:	NC
Zip	:	27105-6526
Country	:	US
Telephone Number	:	336-748-9028
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/21/2008
Last Update Date	:	08/21/2008

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