Basic Information
| Provider Information | |||||||||
| NPI: | 1417008764 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WILES | ||||||||
| FirstName: | ANITA | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | LCSW, COTP | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 538622 | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303538622 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9107429243 | ||||||||
| FaxNumber: | 8887461787 | ||||||||
| Practice Location | |||||||||
| Address1: | 2103 E PARHAM RD | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | RICHMOND | ||||||||
| State: | VA | ||||||||
| PostalCode: | 232282235 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8042612090 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/15/2007 | ||||||||
| LastUpdateDate: | 08/29/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | 0812000510 | VA | N | Behavioral Health & Social Service Providers | Counselor | 1041C0700X | 0904003558 | VA | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 010063752 | 05 | VA | MEDICAID | 004942418 | 05 | VA | MEDICAID | 010050499 | 05 | VA | MEDICAID |