Healthcare Provider Details

I. General information

NPI: 1881459113
Provider Name (Legal Business Name): LYNN WISNER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/15/2024
Last Update Date: 02/15/2024
Certification Date: 02/14/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11350 MCCORMICK RD EXECUTIVE PLAZA 1 SUITE 800
HUNT VALLEY MD
21131
US

IV. Provider business mailing address

2309 MONKTON RD
MONKTON MD
21111-1625
US

V. Phone/Fax

Practice location:
  • Phone: 410-800-2169
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number10814
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: