Provider Demographics
NPI:1770645509
Name:WILKERSON, ANITA GAIL (PHD)
Entity Type:Individual
Prefix:DR
First Name:ANITA
Middle Name:GAIL
Last Name:WILKERSON
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:121 UNIVERSE DR
Mailing Address - Street 2:
Mailing Address - City:MARTINSBURG
Mailing Address - State:WV
Mailing Address - Zip Code:25404-3567
Mailing Address - Country:US
Mailing Address - Phone:304-260-0034
Mailing Address - Fax:303-260-9224
Practice Address - Street 1:121 UNIVERSE DR
Practice Address - Street 2:
Practice Address - City:MARTINSBURG
Practice Address - State:WV
Practice Address - Zip Code:25404-3567
Practice Address - Country:US
Practice Address - Phone:304-260-0034
Practice Address - Fax:303-260-9224
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-15
Last Update Date:2007-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV787103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV9205064000Medicaid
WV9205064000Medicaid