Healthcare Provider Details

I. General information

NPI: 1003579764
Provider Name (Legal Business Name): TAKISHA WILSON LGPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/20/2021
Last Update Date: 12/30/2025
Certification Date: 12/30/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2714 PRINCESS VICTORIA WAY
BOWIE MD
20721-2439
US

IV. Provider business mailing address

2714 PRINCESS VICTORIA WAY
BOWIE MD
20721-2439
US

V. Phone/Fax

Practice location:
  • Phone: 201-341-0153
  • Fax:
Mailing address:
  • Phone: 201-341-0153
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLC16674
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: