Provider Demographics
NPI:1184994675
Name:WESLEY, CLARENCE EDWARD (PERSONAL PROVIDER)
Entity type:Individual
Prefix:MR
First Name:CLARENCE
Middle Name:EDWARD
Last Name:WESLEY
Suffix:
Gender:M
Credentials:PERSONAL PROVIDER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2539 GALTS MILL RD
Mailing Address - Street 2:
Mailing Address - City:MADISON HEIGHTS
Mailing Address - State:VA
Mailing Address - Zip Code:24572-5808
Mailing Address - Country:US
Mailing Address - Phone:434-316-4778
Mailing Address - Fax:434-845-0856
Practice Address - Street 1:2539 GALTS MILL RD
Practice Address - Street 2:2539 GALTS MILL RD
Practice Address - City:MADISON HEIGHTS
Practice Address - State:VA
Practice Address - Zip Code:24572-5808
Practice Address - Country:US
Practice Address - Phone:434-316-4778
Practice Address - Fax:434-845-0856
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-30
Last Update Date:2011-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA320700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320700000XResidential Treatment FacilitiesResidential Treatment Facility, Physical Disabilities