Healthcare Provider Details

I. General information

NPI: 1033261102
Provider Name (Legal Business Name): ELIZABETH V WHEELER PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/17/2007
Last Update Date: 11/06/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25 MIDDLE STREET
PORTLAND ME
04101
US

IV. Provider business mailing address

25 MIDDLE STREET
PORTLAND ME
04101
US

V. Phone/Fax

Practice location:
  • Phone: 207-712-1853
  • Fax: 207-773-5512
Mailing address:
  • Phone: 207-712-1853
  • Fax: 207-773-5512

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberPS1130
License Number StateME
# 2
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPS1130
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: