Basic Information
| Provider Information | |||||||||
| NPI: | 1912101536 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WILEY | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | GENE | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MA, MFT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1400 EMELINE AVE | ||||||||
| Address2: | CHILDREN'S MENTAL HEALTH | ||||||||
| City: | SANTA CRUZ | ||||||||
| State: | CA | ||||||||
| PostalCode: | 950601976 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8314544925 | ||||||||
| FaxNumber: | 8314544916 | ||||||||
| Practice Location | |||||||||
| Address1: | 1400 EMELINE AVE | ||||||||
| Address2: | CHILDREN'S MENTAL HEALTH | ||||||||
| City: | SANTA CRUZ | ||||||||
| State: | CA | ||||||||
| PostalCode: | 950601976 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8314544925 | ||||||||
| FaxNumber: | 8314544916 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/14/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106H00000X | MFC28812 | CA | Y | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
ID Information
| ID | Type | State | Issuer | Description | MFC28812 | 01 | CA | MFT LICENSE NUMBER | OTHER |