Healthcare Provider Details

I. General information

NPI: 1588148449
Provider Name (Legal Business Name): MRS. ZENDY WILSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/17/2018
Last Update Date: 01/16/2024
Certification Date: 01/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 E PRATT ST FL 8
BALTIMORE MD
21202-3180
US

IV. Provider business mailing address

8558 BLACK STAR CIR
COLUMBIA MD
21045-2649
US

V. Phone/Fax

Practice location:
  • Phone: 855-832-6727
  • Fax: 772-675-9100
Mailing address:
  • Phone: 195-462-9202
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License NumberLBA1732
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: