MEDICARE: MARSHA L WILKISON ED S LMHP

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	106H00000X	Marriage & Family Therapist	1732	NE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier Issuer
1	6251	OTHER	MIDLANDS CHOICE
2	84892	OTHER	BCBS DIRECT PROVIDER
3	97085	OTHER	BCBS AUXILLIARY PROVIDER

General Provider Information

NPI Number	:	1790717288
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARSHA L WILKISON ED S LMHP

Provider Business Mailing Address
First Line	:	1012 W 3RD ST
Second Line	:	PO BOX 818
City	:	MCCOOK
State	:	NE
Zip	:	69001-2527
Country	:	US
Telephone Number	:	308-345-2770
Fax Number	:	308-345-2557

Provider Business Practice Location Address
First Line	:	1012 W 3RD ST
Second Line	:
City	:	MCCOOK
State	:	NE
Zip	:	69001-2527
Country	:	US
Telephone Number	:	308-345-2770
Fax Number	:	308-345-2557

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

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

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