Basic Information
| Provider Information | |||||||||
| NPI: | 1366738734 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | TERESA S. WILSON LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 21 N ROLLING RD | ||||||||
| Address2: | |||||||||
| City: | CATONSVILLE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212284849 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4102277191 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1050 17TH ST NW | ||||||||
| Address2: | SUITE 1000 | ||||||||
| City: | WASHINGTON | ||||||||
| State: | DC | ||||||||
| PostalCode: | 200365503 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4102277191 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/23/2011 | ||||||||
| LastUpdateDate: | 06/23/2011 | ||||||||
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| AuthorizedOfficialLastName: | WILSON | ||||||||
| AuthorizedOfficialFirstName: | TERESA | ||||||||
| AuthorizedOfficialMiddleName: | SHARLENE | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 4102277191 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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| AuthorizedOfficialCredential: | LPC, LMFT | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | LMFT000138 | DC | N | Agencies | Community/Behavioral Health | 251S00000X | PRC14103 | DC | Y | Agencies | Community/Behavioral Health |
ID Information
| ID | Type | State | Issuer | Description | 1437450988 | 01 | NPI TYPE 1 | OTHER |