Provider Demographics
NPI:1174848824
Name:WHEELER, MARIJANE (MA, LISAC)
Entity Type:Individual
Prefix:MS
First Name:MARIJANE
Middle Name:
Last Name:WHEELER
Suffix:
Gender:F
Credentials:MA, LISAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:BOX 777 ROUTE 7
Mailing Address - Street 2:
Mailing Address - City:CHINLE
Mailing Address - State:AZ
Mailing Address - Zip Code:86503-0777
Mailing Address - Country:US
Mailing Address - Phone:928-674-2190
Mailing Address - Fax:928-674-2198
Practice Address - Street 1:ROUTE 7
Practice Address - Street 2:BOX 777
Practice Address - City:CHINLE
Practice Address - State:AZ
Practice Address - Zip Code:86503-0777
Practice Address - Country:US
Practice Address - Phone:928-674-2190
Practice Address - Fax:928-674-2198
Is Sole Proprietor?:No
Enumeration Date:2010-04-06
Last Update Date:2010-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ11385101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)