Healthcare Provider Details

I. General information

NPI: 1467904276
Provider Name (Legal Business Name): MICHAEL WENISCH LCPC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/27/2016
Last Update Date: 10/27/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6004 WATERLOO RD
COLUMBIA MD
21045-2631
US

IV. Provider business mailing address

1208 E CHURCHVILLE RD SUITE 300
BEL AIR MD
21014-3442
US

V. Phone/Fax

Practice location:
  • Phone: 410-893-4600
  • Fax: 443-640-4358
Mailing address:
  • Phone: 410-893-4600
  • Fax: 443-640-4358

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLC7438
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: