Healthcare Provider Details

I. General information

NPI: 1700376563
Provider Name (Legal Business Name): EMILY WIETMARSCHEN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/16/2018
Last Update Date: 05/16/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10005 OLD COLUMBIA RD STE L260
COLUMBIA MD
21046-1722
US

IV. Provider business mailing address

8500 16TH ST APT T2
SILVER SPRING MD
20910-2928
US

V. Phone/Fax

Practice location:
  • Phone: 443-259-0400
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLGPC00187
License Number StateDC
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLC8658
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: