Provider Demographics
NPI:1245246206
Name:WILK, ROSE ANN (MS)
Entity Type:Individual
Prefix:
First Name:ROSE
Middle Name:ANN
Last Name:WILK
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1243 SHED RD
Mailing Address - Street 2:
Mailing Address - City:BEDFORD
Mailing Address - State:PA
Mailing Address - Zip Code:15522-8584
Mailing Address - Country:US
Mailing Address - Phone:814-623-5166
Mailing Address - Fax:814-623-3460
Practice Address - Street 1:1243 SHED RD
Practice Address - Street 2:
Practice Address - City:BEDFORD
Practice Address - State:PA
Practice Address - Zip Code:15522-8584
Practice Address - Country:US
Practice Address - Phone:814-623-5166
Practice Address - Fax:814-623-3460
Is Sole Proprietor?:No
Enumeration Date:2006-07-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
N/A101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1000001750049Medicaid
PA123535Medicare ID - Type Unspecified