Provider Demographics
NPI:1417008764
Name:WILES, ANITA M (LCSW, COTP)
Entity Type:Individual
Prefix:
First Name:ANITA
Middle Name:M
Last Name:WILES
Suffix:
Gender:F
Credentials:LCSW, COTP
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 538622
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30353-8622
Mailing Address - Country:US
Mailing Address - Phone:910-742-9243
Mailing Address - Fax:888-746-1787
Practice Address - Street 1:2103 E PARHAM RD
Practice Address - Street 2:SUITE 100
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23228-2235
Practice Address - Country:US
Practice Address - Phone:804-261-2090
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-15
Last Update Date:2018-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0812000510101Y00000X
VA09040035581041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010063752Medicaid
VA004942418Medicaid
VA010050499Medicaid