Basic Information
| Provider Information | |||||||||
| NPI: | 1437450988 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WILSON | ||||||||
| FirstName: | TERESA | ||||||||
| MiddleName: | S | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LPC, LMFT | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 21 N ROLLING RD | ||||||||
| Address2: | |||||||||
| City: | CATONSVILLE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212284849 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4102277191 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 650 PENNSYLVANIA AVE SE | ||||||||
| Address2: | SUITE 240 | ||||||||
| City: | WASHINGTON | ||||||||
| State: | DC | ||||||||
| PostalCode: | 200034318 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2025445440 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/14/2010 | ||||||||
| LastUpdateDate: | 11/16/2010 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | PRC14103 | DC | Y | Behavioral Health & Social Service Providers | Counselor | Professional | 106H00000X | LMFT000138 | DC | N | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
No ID Information.