Basic Information
| Provider Information | |||||||||
| NPI: | 1902903214 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WILHELM | ||||||||
| FirstName: | LAURA | ||||||||
| MiddleName: | R | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 7000 | ||||||||
| Address2: | |||||||||
| City: | MORGANTOWN | ||||||||
| State: | WV | ||||||||
| PostalCode: | 265077000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3043471290 | ||||||||
| FaxNumber: | 3043471397 | ||||||||
| Practice Location | |||||||||
| Address1: | 501 MORRIS STREET | ||||||||
| Address2: | |||||||||
| City: | CHARLESTON | ||||||||
| State: | WV | ||||||||
| PostalCode: | 25301 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3043411500 | ||||||||
| FaxNumber: | 3043411570 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/20/2006 | ||||||||
| LastUpdateDate: | 10/14/2008 | ||||||||
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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 | 103TC0700X | 805 | WV | Y | Behavioral Health & Social Service Providers | Psychologist | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 9204041000 | 05 | WV | MEDICAID |