=====================================================
General NPI Number Information
=====================================================
NPI Number | 1760652739
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | GAIL M WILSON LCPC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/06/2008
-----------------------------------------------------
Last Update Date | 03/06/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4 NORTH AVENUE SUITE 306
-----------------------------------------------------
City | BEL AIR
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21014-0000
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 410-420-7292
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 84 NEPTUNE DR
-----------------------------------------------------
City | JOPPA
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21085-4539
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 410-538-3805
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | LC0643
-----------------------------------------------------
License Number State | MD
-----------------------------------------------------