Provider Demographics
NPI:1386857084
Name:WILEY, ELIZABETH ALEXANDRA (LCSW)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:ALEXANDRA
Last Name:WILEY
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:ELIZABETH
Other - Middle Name:ALEXANDRA
Other - Last Name:WILEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW
Mailing Address - Street 1:1615 E CYPRESS LN
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72703-3082
Mailing Address - Country:US
Mailing Address - Phone:479-684-9436
Mailing Address - Fax:
Practice Address - Street 1:1615 E CYPRESS LN
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72703-3082
Practice Address - Country:US
Practice Address - Phone:479-684-9436
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-08
Last Update Date:2020-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR3264-C1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical