Basic Information
| Provider Information | |||||||||
| NPI: | 1750597589 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WIMBERLY | ||||||||
| FirstName: | ADONA | ||||||||
| MiddleName: | IRENE | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PH.D., L.C.A.D.C. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | WRIGHT | ||||||||
| OtherFirstName: | ADONA | ||||||||
| OtherMiddleName: | IRENE | ||||||||
| OtherNamePrefix: | DR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 9565 LONG LOOK LN | ||||||||
| Address2: | |||||||||
| City: | COLUMBIA | ||||||||
| State: | MD | ||||||||
| PostalCode: | 210453241 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4436215355 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1447 YORK RD STE 506 | ||||||||
| Address2: | |||||||||
| City: | LUTHERVILLE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 210936022 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4108252281 | ||||||||
| FaxNumber: | 4108252280 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/16/2007 | ||||||||
| LastUpdateDate: | 09/13/2019 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| 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 | 103T00000X | 04227 | MD | N | Behavioral Health & Social Service Providers | Psychologist | 103TC0700X | 04227 | MD | Y | Behavioral Health & Social Service Providers | Psychologist | Clinical | 101Y00000X | LCA124 | MD | N | Behavioral Health & Social Service Providers | Counselor | 101YA0400X | LCA124 | MD | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.