Provider Demographics
NPI:1649427410
Name:WILEY, BRIAN SCOTT (MA)
Entity type:Individual
Prefix:
First Name:BRIAN
Middle Name:SCOTT
Last Name:WILEY
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11502 OLDE TIVERTON CIR
Mailing Address - Street 2:305
Mailing Address - City:RESTON
Mailing Address - State:VA
Mailing Address - Zip Code:20194-1915
Mailing Address - Country:US
Mailing Address - Phone:703-796-1183
Mailing Address - Fax:703-796-1183
Practice Address - Street 1:11502 OLDE TIVERTON CIR
Practice Address - Street 2:305
Practice Address - City:RESTON
Practice Address - State:VA
Practice Address - Zip Code:20194-1915
Practice Address - Country:US
Practice Address - Phone:703-796-1183
Practice Address - Fax:703-796-1183
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-25
Last Update Date:2008-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0803000220103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool