Healthcare Provider Details

I. General information

NPI: 1346417946
Provider Name (Legal Business Name): BRENDA E WILEY PT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/13/2008
Last Update Date: 05/13/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6801 LUCY CORR CT
CHESTERFIELD VA
23832-6657
US

IV. Provider business mailing address

6801 LUCY CORR CT
CHESTERFIELD VA
23832-6657
US

V. Phone/Fax

Practice location:
  • Phone: 804-748-1227
  • Fax: 804-717-6659
Mailing address:
  • Phone: 804-748-1227
  • Fax: 804-717-6659

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251P0200X
TaxonomyPediatric Physical Therapist
License Number2305000634
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: