Healthcare Provider Details

I. General information

NPI: 1235004482
Provider Name (Legal Business Name): LUKE SAMUEL WIGDAHL
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/08/2025
Last Update Date: 10/08/2025
Certification Date: 10/08/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1653 E MAIN ST
EASLEY SC
29640-3791
US

IV. Provider business mailing address

1653 E MAIN ST
EASLEY SC
29640-3791
US

V. Phone/Fax

Practice location:
  • Phone: 888-711-2896
  • Fax:
Mailing address:
  • Phone: 888-711-2896
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number StateSC

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: