Healthcare Provider Details

I. General information

NPI: 1558610345
Provider Name (Legal Business Name): CHRISTY LYNN WASILENKO LCSW-C, LICSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/07/2012
Last Update Date: 09/07/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3701 EASTERN AVE
BALTIMORE MD
21224-4208
US

IV. Provider business mailing address

PO BOX 43361
NOTTINGHAM MD
21236-0361
US

V. Phone/Fax

Practice location:
  • Phone: 443-517-9979
  • Fax:
Mailing address:
  • Phone: 443-517-9979
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLC50079168
License Number StateDC
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number12664
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: