MEDICARE: BRENDA S. WILKERSON LCSW, CAC III

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	101YA0400X	Addiction (Substance Use Disorder) Counselor	6196	CO
2	1041C0700X	Clinical Social Worker	992923	CO

General Provider Information

NPI Number	:	1922117852
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BRENDA S. WILKERSON LCSW, CAC III

Provider Business Mailing Address
First Line	:	1627 PROSPECT ESTATES DR
Second Line	:
City	:	ESTES PARK
State	:	CO
Zip	:	80517-7203
Country	:	US
Telephone Number	:	970-577-0635
Fax Number	:

Provider Business Practice Location Address
First Line	:	1627 PROSPECT ESTATES DR
Second Line	:
City	:	ESTES PARK
State	:	CO
Zip	:	80517-7203
Country	:	US
Telephone Number	:	970-586-9105
Fax Number	:	970-586-9491

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

Provider Enumeration Date	:	08/30/2006
Last Update Date	:	04/25/2010

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