Basic Information
| Provider Information | |||||||||
| NPI: | 1508038894 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WILKS | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | ELIZABETH | ||||||||
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| Credential: | LCSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3801 NORTH BLVD | ||||||||
| Address2: | |||||||||
| City: | BATON ROUGE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 708063825 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2253816696 | ||||||||
| FaxNumber: | 2253812536 | ||||||||
| Practice Location | |||||||||
| Address1: | 3801 NORTH BLVD | ||||||||
| Address2: | |||||||||
| City: | BATON ROUGE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 708063825 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2253816696 | ||||||||
| FaxNumber: | 2253812536 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/27/2008 | ||||||||
| LastUpdateDate: | 03/27/2008 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 3636 | LA | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.