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General NPI Number Information
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NPI Number | 1467033324
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Entity Type | Individual
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Provider Name | MICHELLE K WILEY
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Gender | Female
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Dates
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Enumeration Date | 04/20/2021
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Last Update Date | 04/20/2021
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Provider Practice Location Address
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Address Line | 1000 MAIN ST
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City | PORT JEFFERSON
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State | NY
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Zip | 11777-2250
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Country | US
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Telephone | 516-993-6678
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Fax |
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Provider Business Mailing Address
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Address Line | 114 EVERGREEN AVE FL 2
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City | LYNBROOK
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State | NY
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Zip | 11563-3162
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Country | US
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Telephone | 516-476-6545
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 106H00000X
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Taxonomy Name | Marriage & Family Therapist
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License Number | 001749
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License Number State | NY
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