Healthcare Provider Details

I. General information

NPI: 1821776642
Provider Name (Legal Business Name): CAROLYN WILSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/11/2023
Last Update Date: 08/31/2026
Certification Date: 08/31/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3007 LOGAN ST
DISTRICT HEIGHTS MD
20747-2728
US

IV. Provider business mailing address

3007 LOGAN ST
DISTRICT HEIGHTS MD
20747-2728
US

V. Phone/Fax

Practice location:
  • Phone: 202-621-4742
  • Fax:
Mailing address:
  • Phone: 202-621-4742
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateDC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: