Healthcare Provider Details

I. General information

NPI: 1790849453
Provider Name (Legal Business Name): AMY R WIELKOPOLAN LMBT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/20/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4370 CREPE MYRTLE CT UNIT A
MURRELLS INLET SC
29576-4307
US

IV. Provider business mailing address

4370 CREPE MYRTLE CT UNIT A
MURRELLS INLET SC
29576-4307
US

V. Phone/Fax

Practice location:
  • Phone: 843-504-2905
  • Fax: --
Mailing address:
  • Phone: 843-504-2905
  • Fax: --

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code302R00000X
TaxonomyHealth Maintenance Organization
License Number3663
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: