Healthcare Provider Details

I. General information

NPI: 1326875519
Provider Name (Legal Business Name): ALICE WYSOCKI LGPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/19/2024
Last Update Date: 10/23/2024
Certification Date: 10/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

59 KATE WAGNER RD
WESTMINSTER MD
21157-6957
US

IV. Provider business mailing address

815 RITCHIE HWY STE 112
SEVERNA PARK MD
21146-4192
US

V. Phone/Fax

Practice location:
  • Phone: 410-848-2500
  • Fax:
Mailing address:
  • Phone: 667-500-4556
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLGP15631
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: