Basic Information
| Provider Information | |||||||||
| NPI: | 1437161585 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WISSMAN | ||||||||
| FirstName: | KATHERINE | ||||||||
| MiddleName: | BLAIR | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LSCW-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6123 MONTROSE RD | ||||||||
| Address2: | |||||||||
| City: | ROCKVILLE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 208524860 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3018384200 | ||||||||
| FaxNumber: | 3013092596 | ||||||||
| Practice Location | |||||||||
| Address1: | 6123 MONTROSE RD | ||||||||
| Address2: | |||||||||
| City: | ROCKVILLE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 20852 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3018813700 | ||||||||
| FaxNumber: | 3014681862 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/13/2006 | ||||||||
| LastUpdateDate: | 04/24/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | 12093 | MD | Y | Behavioral Health & Social Service Providers | Social Worker |
ID Information
| ID | Type | State | Issuer | Description | 403337000 | 05 | MD | MEDICAID | 622642 01 | 01 | MD | BCBS OF MD | OTHER | 236676 | 01 | MD | KAISER | OTHER | 589530000 | 01 | MD | MAGELLAN | OTHER | 7134551 | 01 | MD | AETNA | OTHER | A2840130 | 01 | DC | BCBS OF DC | OTHER |