MEDICARE: WANDA WILSON LICSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor	LC302836	DC

General Provider Information

NPI Number	:	1265650758
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	WANDA WILSON LICSW

Provider Business Mailing Address
First Line	:	6503 LACONA ST
Second Line	:
City	:	FORESTVILLE
State	:	MD
Zip	:	20747-2882
Country	:	US
Telephone Number	:	301-735-4838
Fax Number	:

Provider Business Practice Location Address
First Line	:	51 N ST NE
Second Line	:
City	:	WASHINGTON
State	:	DC
Zip	:	20002-3347
Country	:	US
Telephone Number	:	202-442-6077
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/23/2007
Last Update Date	:	07/08/2007

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