Provider Demographics
NPI:1366908220
Name:LITTLE, WESLEY DION
Entity type:Individual
Prefix:
First Name:WESLEY
Middle Name:DION
Last Name:LITTLE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:40 PRINCETON LN
Mailing Address - Street 2:
Mailing Address - City:WILLINGBORO
Mailing Address - State:NJ
Mailing Address - Zip Code:08046-2739
Mailing Address - Country:US
Mailing Address - Phone:609-556-9611
Mailing Address - Fax:
Practice Address - Street 1:40 PRINCETON LN
Practice Address - Street 2:
Practice Address - City:WILLINGBORO
Practice Address - State:NJ
Practice Address - Zip Code:08046-2739
Practice Address - Country:US
Practice Address - Phone:609-556-9611
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-15
Last Update Date:2019-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X, 372600000X, 374U00000X, 372500000X, 174H00000X
NJ171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174H00000XOther Service ProvidersHealth Educator
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
No372600000XNursing Service Related ProvidersAdult Companion
No374U00000XNursing Service Related ProvidersHome Health Aide
No372500000XNursing Service Related ProvidersChore Provider
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0400248522Medicaid