Provider Demographics
NPI:1588190128
Name:WILEY, ANDREA (LCSW, MAC)
Entity Type:Individual
Prefix:
First Name:ANDREA
Middle Name:
Last Name:WILEY
Suffix:
Gender:F
Credentials:LCSW, MAC
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 16089
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23222-0289
Mailing Address - Country:US
Mailing Address - Phone:336-392-9523
Mailing Address - Fax:804-359-5137
Practice Address - Street 1:312 GRANITE AVE OFC 2
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23226-2144
Practice Address - Country:US
Practice Address - Phone:336-392-9523
Practice Address - Fax:804-359-5137
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-02
Last Update Date:2017-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA510113101YA0400X
VA09040008291041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)