Provider Demographics
NPI:1831162569
Name:WILKS, EDWARD GEORGE (PSYD)
Entity type:Individual
Prefix:DR
First Name:EDWARD
Middle Name:GEORGE
Last Name:WILKS
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3551 ROGER BROOKE DR
Mailing Address - Street 2:
Mailing Address - City:FORT SAM HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:78234-4504
Mailing Address - Country:US
Mailing Address - Phone:210-323-9267
Mailing Address - Fax:
Practice Address - Street 1:BROOKE ARMY MEDICAL CENTER
Practice Address - Street 2:3551 ROGER BROOKE DR.
Practice Address - City:JBSA FORT SAM HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:78234
Practice Address - Country:US
Practice Address - Phone:210-916-5792
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-13
Last Update Date:2023-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX31784103TC1900X
TX303106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
Not Answered106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1831162569Medicaid