Healthcare Provider Details

I. General information

NPI: 1588190128
Provider Name (Legal Business Name): ANDREA WILEY LCSW, MAC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/02/2017
Last Update Date: 12/14/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

312 GRANITE AVE OFC 2
RICHMOND VA
23226-2144
US

IV. Provider business mailing address

PO BOX 16089
RICHMOND VA
23222-0289
US

V. Phone/Fax

Practice location:
  • Phone: 336-392-9523
  • Fax: 804-359-5137
Mailing address:
  • Phone: 336-392-9523
  • Fax: 804-359-5137

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number510113
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number0904000829
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: