Healthcare Provider Details

I. General information

NPI: 1932575271
Provider Name (Legal Business Name): TORI ANN WILSON LCPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: TORI ANN MARNELL LCPC

II. Dates (important events)

Enumeration Date: 08/20/2015
Last Update Date: 08/20/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1330 MCCORMICK DR
LARGO MD
20774-5398
US

IV. Provider business mailing address

1330 MCCORMICK DR
LARGO MD
20774-5398
US

V. Phone/Fax

Practice location:
  • Phone: 301-772-1200
  • Fax: 301-386-4479
Mailing address:
  • Phone: 301-772-1200
  • Fax: 301-386-4479

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLC2744
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: