Healthcare Provider Details

I. General information

NPI: 1437161585
Provider Name (Legal Business Name): KATHERINE BLAIR WISSMAN LSCW-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/13/2006
Last Update Date: 04/24/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6123 MONTROSE RD
ROCKVILLE MD
20852
US

IV. Provider business mailing address

6123 MONTROSE RD
ROCKVILLE MD
20852-4860
US

V. Phone/Fax

Practice location:
  • Phone: 301-881-3700
  • Fax: 301-468-1862
Mailing address:
  • Phone: 301-838-4200
  • Fax: 301-309-2596

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number12093
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: