Provider Demographics
NPI:1396964839
Name:WILEY, MICHAEL E (LCSW)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:E
Last Name:WILEY
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5563 W LUCKY DR
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83703-3188
Mailing Address - Country:US
Mailing Address - Phone:208-724-9276
Mailing Address - Fax:
Practice Address - Street 1:2805 BLAINE ST
Practice Address - Street 2:STE 120
Practice Address - City:CALDWELL
Practice Address - State:ID
Practice Address - Zip Code:83605-4599
Practice Address - Country:US
Practice Address - Phone:208-459-4412
Practice Address - Fax:208-454-7296
Is Sole Proprietor?:No
Enumeration Date:2007-04-24
Last Update Date:2011-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLCSW-8041041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical