Healthcare Provider Details

I. General information

NPI: 1144559501
Provider Name (Legal Business Name): COURTNEY LEIGH WUNDERLICH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/15/2009
Last Update Date: 12/15/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 MEMORIAL AVE
WESTMINSTER MD
21157-5726
US

IV. Provider business mailing address

200 MEMORIAL AVE
WESTMINSTER MD
21157-5726
US

V. Phone/Fax

Practice location:
  • Phone: 410-871-6971
  • Fax:
Mailing address:
  • Phone: 410-871-6971
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number15449
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: