=====================================================
General NPI Number Information
=====================================================
NPI Number | 1972989895
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | WILLIE DWAYNE DOCTOR JR. LCSW-C
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/03/2015
-----------------------------------------------------
Last Update Date | 02/24/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9002 PHILLIP DORSEY WAY
-----------------------------------------------------
City | COLUMBIA
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21045-5149
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 301-920-4514
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 6211
-----------------------------------------------------
City | COLUMBIA
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21045-6211
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 301-920-4514
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 20933
-----------------------------------------------------
License Number State | MD
-----------------------------------------------------