Basic Information
Provider Information | |||||||||
NPI: | 1265595680 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | WICKLINE | ||||||||
FirstName: | LELIA | ||||||||
MiddleName: | A. T. | ||||||||
NamePrefix: | MRS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | LCSW | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1241 N MAIN ST | ||||||||
Address2: |   | ||||||||
City: | HARRISONBURG | ||||||||
State: | VA | ||||||||
PostalCode: | 228024632 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5404341941 | ||||||||
FaxNumber: | 5404340132 | ||||||||
Practice Location | |||||||||
Address1: | 1241 N MAIN ST | ||||||||
Address2: |   | ||||||||
City: | HARRISONBURG | ||||||||
State: | VA | ||||||||
PostalCode: | 228024632 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5404341941 | ||||||||
FaxNumber: | 5404340132 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/18/2006 | ||||||||
LastUpdateDate: | 05/08/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 05/08/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X |   |   | Y |   | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
ID | Type | State | Issuer | Description | 249731 | 01 | VA | ANTHEM | OTHER | 0802905M | 01 | VA | SENTARA | OTHER | 1265595680 | 05 | VA |   | MEDICAID | 404226 | 01 | VA | TRICARE | OTHER | 11705255 | 01 | VA | CAQH | OTHER | 2159589 | 01 | VA | COMPSYCH | OTHER | 1164637518 | 01 | VA | GROUP NPI NUMBER | OTHER | 2345972 | 01 | VA | CIGNA | OTHER |