MEDICARE: WISE ROADS TO HEALING, LLC

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	1041C0700X	Clinical Social Worker

General Provider Information

NPI Number	:	1477274140
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WISE ROADS TO HEALING, LLC

Provider Business Mailing Address
First Line	:	509 QUINCE ORCHARD RD STE 338
Second Line	:
City	:	GAITHERSBURG
State	:	MD
Zip	:	20878-1435
Country	:	US
Telephone Number	:	301-660-3141
Fax Number	:

Provider Business Practice Location Address
First Line	:	509 QUINCE ORCHARD RD STE 338
Second Line	:
City	:	GAITHERSBURG
State	:	MD
Zip	:	20878-1435
Country	:	US
Telephone Number	:	301-660-3141
Fax Number	:

Authorized Official
Title or Position	:	PSYCHOTHERAPIST
Name	:	WYNESHIA R HICKS
Credential	:	LCSW-C
Telephone Number	:	917-885-8677

Provider Enumeration Date	:	09/09/2022
Last Update Date	:	09/09/2022

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