Healthcare Provider Details

I. General information

NPI: 1578896890
Provider Name (Legal Business Name): WILFRIED C VEREECKE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/18/2009
Last Update Date: 09/18/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4100 NEBRASKA AVE NW
WASHINGTON DC
20016-2736
US

IV. Provider business mailing address

4100 NEBRASKA AVE NW
WASHINGTON DC
20016-2736
US

V. Phone/Fax

Practice location:
  • Phone: 202-363-1841
  • Fax: 202-363-1841
Mailing address:
  • Phone: 202-363-1841
  • Fax: 202-363-1841

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberPRC14002
License Number StateDC
# 2
Primary TaxonomyN
Taxonomy Code102L00000X
TaxonomyPsychoanalyst
License NumberADVANCED CANDIDATE
License Number StateDC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: