Provider Demographics
NPI:1720136310
Name:RASBURY, WILEY C (PHD)
Entity Type:Individual
Prefix:
First Name:WILEY
Middle Name:C
Last Name:RASBURY
Suffix:
Gender:M
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:HENRY FORD HEALTH SYSTEM
Mailing Address - Street 2:ONE FORD PLACE 1F -BEHAVIORAL
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48202
Mailing Address - Country:US
Mailing Address - Phone:313-876-6677
Mailing Address - Fax:
Practice Address - Street 1:HENRY FORD HEALTH SYSTEM
Practice Address - Street 2:ONE FORD PLACE 1F -BEHAVIORAL
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48202
Practice Address - Country:US
Practice Address - Phone:313-876-6677
Practice Address - Fax:313-874-6650
Is Sole Proprietor?:No
Enumeration Date:2007-01-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI63010053112084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIPHD888810Medicaid
WR005311OtherCOMMERCIAL-COMMERCIAL NUMBER
WR005311OtherCHAMPUS-CHAMPUS
WR005311OtherCHAMPUS-CHAMPUS