Provider Demographics
NPI: | 1033261102 |
---|---|
Name: | WHEELER, ELIZABETH V (PHD) |
Entity Type: | Individual |
Prefix: | DR |
First Name: | ELIZABETH |
Middle Name: | V |
Last Name: | WHEELER |
Suffix: | |
Gender: | F |
Credentials: | PHD |
Other - Prefix: | |
Other - First Name: | |
Other - Middle Name: | |
Other - Last Name: | |
Other - Suffix: | |
Other - Last Name Type: | |
Other - Credentials: | |
Mailing Address - Street 1: | 25 MIDDLE STREET |
Mailing Address - Street 2: | |
Mailing Address - City: | PORTLAND |
Mailing Address - State: | ME |
Mailing Address - Zip Code: | 04101 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 207-712-1853 |
Mailing Address - Fax: | 207-773-5512 |
Practice Address - Street 1: | 25 MIDDLE STREET |
Practice Address - Street 2: | |
Practice Address - City: | PORTLAND |
Practice Address - State: | ME |
Practice Address - Zip Code: | 04101 |
Practice Address - Country: | US |
Practice Address - Phone: | 207-712-1853 |
Practice Address - Fax: | 207-773-5512 |
Is Sole Proprietor?: | Yes |
Enumeration Date: | 2007-01-17 |
Last Update Date: | 2015-11-06 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
ME | PS1130 | 103TC0700X, 103T00000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 103TC0700X | Behavioral Health & Social Service Providers | Psychologist | Clinical |
No | 103T00000X | Behavioral Health & Social Service Providers | Psychologist |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
ME | 017608 | Other | VALUE OPTIONS |
ME | 431546200 | Medicaid | |
ME | 048089 | Other | ANTHEM |
ME | 431546200 | Medicaid |