Provider Demographics
NPI:1497906226
Name:WILEY, TERRY
Entity Type:Individual
Prefix:
First Name:TERRY
Middle Name:
Last Name:WILEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:116 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:SHAWANO
Mailing Address - State:WI
Mailing Address - Zip Code:54166-2356
Mailing Address - Country:US
Mailing Address - Phone:715-526-7370
Mailing Address - Fax:715-526-7294
Practice Address - Street 1:116 N MAIN ST
Practice Address - Street 2:
Practice Address - City:SHAWANO
Practice Address - State:WI
Practice Address - Zip Code:54166-2356
Practice Address - Country:US
Practice Address - Phone:715-526-7370
Practice Address - Fax:715-526-7294
Is Sole Proprietor?:No
Enumeration Date:2008-10-10
Last Update Date:2008-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI445-27224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI41076100Medicaid