Provider Demographics
NPI:1093717829
Name:WILEY, JOHN MICHAEL (MSW)
Entity Type:Individual
Prefix:MR
First Name:JOHN
Middle Name:MICHAEL
Last Name:WILEY
Suffix:
Gender:M
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1210 10TH ST
Mailing Address - Street 2:SUITE 203
Mailing Address - City:BELLINGHAM
Mailing Address - State:WA
Mailing Address - Zip Code:98225-7063
Mailing Address - Country:US
Mailing Address - Phone:360-527-0591
Mailing Address - Fax:360-647-1043
Practice Address - Street 1:1210 10TH ST
Practice Address - Street 2:SUITE 203
Practice Address - City:BELLINGHAM
Practice Address - State:WA
Practice Address - Zip Code:98225-7063
Practice Address - Country:US
Practice Address - Phone:360-527-0591
Practice Address - Fax:360-647-1043
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALW00004986104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
WALW00004986OtherDEPT OF HEALTH
AB01612Medicare ID - Type Unspecified