Provider Demographics
NPI:1912101536
Name:WILEY, MICHAEL GENE (MA, MFT)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:GENE
Last Name:WILEY
Suffix:
Gender:M
Credentials:MA, MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1400 EMELINE AVE
Mailing Address - Street 2:CHILDREN'S MENTAL HEALTH
Mailing Address - City:SANTA CRUZ
Mailing Address - State:CA
Mailing Address - Zip Code:95060-1976
Mailing Address - Country:US
Mailing Address - Phone:831-454-4925
Mailing Address - Fax:831-454-4916
Practice Address - Street 1:1400 EMELINE AVE
Practice Address - Street 2:CHILDREN'S MENTAL HEALTH
Practice Address - City:SANTA CRUZ
Practice Address - State:CA
Practice Address - Zip Code:95060-1976
Practice Address - Country:US
Practice Address - Phone:831-454-4925
Practice Address - Fax:831-454-4916
Is Sole Proprietor?:No
Enumeration Date:2007-06-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC28812106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAMFC28812OtherMFT LICENSE NUMBER