Provider Demographics
NPI:1902963390
Name:WILES, LOU ANN (MFT)
Entity Type:Individual
Prefix:
First Name:LOU
Middle Name:ANN
Last Name:WILES
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4096 BRIDGE ST
Mailing Address - Street 2:SUITE 7
Mailing Address - City:FAIR OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:95628-7163
Mailing Address - Country:US
Mailing Address - Phone:916-966-1356
Mailing Address - Fax:916-966-1356
Practice Address - Street 1:4096 BRIDGE ST
Practice Address - Street 2:SUITE 7
Practice Address - City:FAIR OAKS
Practice Address - State:CA
Practice Address - Zip Code:95628-7163
Practice Address - Country:US
Practice Address - Phone:916-966-1356
Practice Address - Fax:916-966-1356
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC32660106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist