MEDICARE: ETHAN RICHARD WILEY I

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	106S00000X	Behavior Technician		VA

General Provider Information

NPI Number	:	1538019278
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ETHAN RICHARD WILEY I

Provider Business Mailing Address
First Line	:	1363 W BROAD ST APT 306
Second Line	:
City	:	RICHMOND
State	:	VA
Zip	:	23220-3042
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2920 W BROAD ST STE 215
Second Line	:
City	:	RICHMOND
State	:	VA
Zip	:	23230-5103
Country	:	US
Telephone Number	:	800-883-8441
Fax Number	:

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

Provider Enumeration Date	:	02/02/2026
Last Update Date	:	02/02/2026

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