Provider Demographics
NPI:1902903214
Name:WILHELM, LAURA R
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:R
Last Name:WILHELM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 7000
Mailing Address - Street 2:
Mailing Address - City:MORGANTOWN
Mailing Address - State:WV
Mailing Address - Zip Code:26507-7000
Mailing Address - Country:US
Mailing Address - Phone:304-347-1290
Mailing Address - Fax:304-347-1397
Practice Address - Street 1:501 MORRIS STREET
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25301
Practice Address - Country:US
Practice Address - Phone:304-341-1500
Practice Address - Fax:304-341-1570
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2008-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV805103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV9204041000Medicaid
WVWICP25551Medicare PIN
P47309Medicare UPIN