Basic Information
| Provider Information | |||||||||
| NPI: | 1538536131 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WILEY | ||||||||
| FirstName: | STACEY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2904 ARKANSAS BLVD | ||||||||
| Address2: | |||||||||
| City: | TEXARKANA | ||||||||
| State: | AR | ||||||||
| PostalCode: | 718542536 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8707734655 | ||||||||
| FaxNumber: | 8707724650 | ||||||||
| Practice Location | |||||||||
| Address1: | 300 E 20TH ST | ||||||||
| Address2: | |||||||||
| City: | HOPE | ||||||||
| State: | AR | ||||||||
| PostalCode: | 718018217 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8707779051 | ||||||||
| FaxNumber: | 8707773104 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/31/2015 | ||||||||
| LastUpdateDate: | 08/31/2015 | ||||||||
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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 | 171M00000X | Y | Other Service Providers | Case Manager/Care Coordinator |
No ID Information.