Provider Demographics
NPI:1316061138
Name:WIMBERLY, ANNIE G
Entity type:Individual
Prefix:
First Name:ANNIE
Middle Name:G
Last Name:WIMBERLY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 959
Mailing Address - Street 2:
Mailing Address - City:YAKIMA
Mailing Address - State:WA
Mailing Address - Zip Code:98907-0959
Mailing Address - Country:US
Mailing Address - Phone:509-575-4084
Mailing Address - Fax:
Practice Address - Street 1:206 S. 2ND AVE.
Practice Address - Street 2:
Practice Address - City:YAKIMA
Practice Address - State:WA
Practice Address - Zip Code:98902
Practice Address - Country:US
Practice Address - Phone:509-575-4084
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-19
Last Update Date:2011-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WARC00049156101YM0800X
WACG601232921101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health