Healthcare Provider Details

I. General information

NPI: 1003413345
Provider Name (Legal Business Name): NADA S WILSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/08/2020
Last Update Date: 06/03/2024
Certification Date: 06/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

VESTA 9301 ANNAPOLIS RD
LANHAM MD
20706-1001
US

IV. Provider business mailing address

11000 HUNTERS VIEW RD
ELLICOTT CITY MD
21042-6109
US

V. Phone/Fax

Practice location:
  • Phone: 240-296-6300
  • Fax:
Mailing address:
  • Phone: 240-271-0079
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLGP12696
License Number StateMD
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLC15076
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: