Healthcare Provider Details

I. General information

NPI: 1811044381
Provider Name (Legal Business Name): DR. MERCEDES E. WILSON DALLAS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/05/2007
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

720 N SAINT ASAPH ST FOURTH FLOOR
ALEXANDRIA VA
22314-1912
US

IV. Provider business mailing address

4906 SHARON RD
CAMP SPRINGS MD
20748-2236
US

V. Phone/Fax

Practice location:
  • Phone: 703-838-6400
  • Fax: 703-838-5070
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number0810001425
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: