=====================================================
General NPI Number Information
=====================================================
NPI Number | 1750597589
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ADONA IRENE WIMBERLY PH.D., L.C.A.D.C.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/16/2007
-----------------------------------------------------
Last Update Date | 09/13/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1447 YORK RD STE 506
-----------------------------------------------------
City | LUTHERVILLE
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21093-6022
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 410-825-2281
-----------------------------------------------------
Fax | 410-825-2280
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9565 LONG LOOK LN
-----------------------------------------------------
City | COLUMBIA
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21045-3241
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 443-621-5355
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103T00000X
-----------------------------------------------------
Taxonomy Name | Psychologist
-----------------------------------------------------
License Number | 04227
-----------------------------------------------------
License Number State | MD
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number | 04227
-----------------------------------------------------
License Number State | MD
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 101Y00000X
-----------------------------------------------------
Taxonomy Name | Counselor
-----------------------------------------------------
License Number | LCA124
-----------------------------------------------------
License Number State | MD
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 101YA0400X
-----------------------------------------------------
Taxonomy Name | Addiction (Substance Use Disorder) Counselor
-----------------------------------------------------
License Number | LCA124
-----------------------------------------------------
License Number State | MD
-----------------------------------------------------