Healthcare Provider Details

I. General information

NPI: 1679352587
Provider Name (Legal Business Name): TANYA WILKERSON LMSW-CC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/28/2023
Last Update Date: 09/28/2023
Certification Date: 09/27/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16 PRESCOTT DRIVE
HINCKLEY ME
04944
US

IV. Provider business mailing address

PO BOX 159
HINCKLEY ME
04944-0159
US

V. Phone/Fax

Practice location:
  • Phone: 207-238-4000
  • Fax:
Mailing address:
  • Phone: 207-238-4000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberMC22502
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: