Provider Demographics
NPI:1275102493
Name:WILEY, BRETT RUSSELL
Entity Type:Individual
Prefix:MR
First Name:BRETT
Middle Name:RUSSELL
Last Name:WILEY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 129
Mailing Address - Street 2:
Mailing Address - City:FARWELL
Mailing Address - State:MI
Mailing Address - Zip Code:48622-0129
Mailing Address - Country:US
Mailing Address - Phone:989-588-6769
Mailing Address - Fax:
Practice Address - Street 1:16 KAPPLINGER DR
Practice Address - Street 2:
Practice Address - City:FARWELL
Practice Address - State:MI
Practice Address - Zip Code:48622-9405
Practice Address - Country:US
Practice Address - Phone:989-588-6769
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-22
Last Update Date:2021-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIAS180407234261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)