Provider Demographics
NPI:1548278989
Name:WILEY, LAURA D (LCSW)
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:D
Last Name:WILEY
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:96 HARLOW ST
Mailing Address - Street 2:SUITE 224
Mailing Address - City:BANGOR
Mailing Address - State:ME
Mailing Address - Zip Code:04401-4925
Mailing Address - Country:US
Mailing Address - Phone:207-945-9754
Mailing Address - Fax:
Practice Address - Street 1:96 HARLOW ST
Practice Address - Street 2:SUITE 224
Practice Address - City:BANGOR
Practice Address - State:ME
Practice Address - Zip Code:04401-4925
Practice Address - Country:US
Practice Address - Phone:207-945-9754
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-03
Last Update Date:2009-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MELC66791041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME31010099Medicaid
MEMM7229Medicare PIN