=====================================================
General NPI Number Information
=====================================================
NPI Number | 1083059166
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MARTHA WIKE, PH.D., P.C.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/02/2013
-----------------------------------------------------
Last Update Date | 05/02/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4006 SUTHERLAND AVE
-----------------------------------------------------
City | KNOXVILLE
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37919-5103
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 865-584-6111
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 11423
-----------------------------------------------------
City | KNOXVILLE
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37939-1423
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 865-584-6111
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. MARTHA WIKE
-----------------------------------------------------
Credential | PH.D.
-----------------------------------------------------
Telephone | 865-584-6111
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number | 1710
-----------------------------------------------------
License Number State | TN
-----------------------------------------------------