Provider Demographics
NPI:1154469559
Name:WILEY, WELTON MIGUEL (LAC, CCS)
Entity Type:Individual
Prefix:MR
First Name:WELTON
Middle Name:MIGUEL
Last Name:WILEY
Suffix:
Gender:M
Credentials:LAC, CCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:189 OSCAR RD
Mailing Address - Street 2:
Mailing Address - City:WEST MONROE
Mailing Address - State:LA
Mailing Address - Zip Code:71292-1298
Mailing Address - Country:US
Mailing Address - Phone:318-396-4904
Mailing Address - Fax:318-362-3268
Practice Address - Street 1:602 E GEORGIA AVE
Practice Address - Street 2:
Practice Address - City:RUSTON
Practice Address - State:LA
Practice Address - Zip Code:71270-3931
Practice Address - Country:US
Practice Address - Phone:318-251-4125
Practice Address - Fax:318-251-5000
Is Sole Proprietor?:No
Enumeration Date:2007-02-01
Last Update Date:2012-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LALAC 880101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)