MEDICARE: MR. JAMES MACK WIGLEY LPC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YP2500X	Professional Counselor	10953	TX

General Provider Information

NPI Number	:	1033127386
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. JAMES MACK WIGLEY LPC

Provider Business Mailing Address
First Line	:	11811 TRAWOOD PATH
Second Line	:
City	:	AUSTIN
State	:	TX
Zip	:	78748-2033
Country	:	US
Telephone Number	:	512-423-6876
Fax Number	:

Provider Business Practice Location Address
First Line	:	11811 TRAWOOD PATH
Second Line	:
City	:	AUSTIN
State	:	TX
Zip	:	78748-2033
Country	:	US
Telephone Number	:	512-423-6876
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/03/2006
Last Update Date	:	07/08/2007

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