MEDICARE: MS. AMY R WIELKOPOLAN LMBT

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	302R00000X	Health Maintenance Organization	3663	SC

General Provider Information

NPI Number	:	1790849453
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. AMY R WIELKOPOLAN LMBT

Provider Business Mailing Address
First Line	:	4370 CREPE MYRTLE CT UNIT A
Second Line	:
City	:	MURRELLS INLET
State	:	SC
Zip	:	29576-4307
Country	:	US
Telephone Number	:	843-504-2905
Fax Number	:	--

Provider Business Practice Location Address
First Line	:	4370 CREPE MYRTLE CT UNIT A
Second Line	:
City	:	MURRELLS INLET
State	:	SC
Zip	:	29576-4307
Country	:	US
Telephone Number	:	843-504-2905
Fax Number	:	--

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

Provider Enumeration Date	:	12/20/2006
Last Update Date	:	07/08/2007

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