Basic Information
| Provider Information | |||||||||
| NPI: | 1780717314 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WILMES | ||||||||
| FirstName: | DONALD | ||||||||
| MiddleName: | B | ||||||||
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| NameSuffix: | |||||||||
| Credential: | PHD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 711 W 40TH ST | ||||||||
| Address2: | SUITE 456A | ||||||||
| City: | BALTIMORE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212112199 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4104671585 | ||||||||
| FaxNumber: | 4102359339 | ||||||||
| Practice Location | |||||||||
| Address1: | 711 W 40TH ST | ||||||||
| Address2: | SUITE 456A | ||||||||
| City: | BALTIMORE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212112199 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4104671585 | ||||||||
| FaxNumber: | 4102359339 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/13/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X | 1259 | MD | Y | Behavioral Health & Social Service Providers | Psychologist |
ID Information
| ID | Type | State | Issuer | Description | 29664 | 01 | MD | HOPKINS EMPLOYEE HEALTH P | OTHER | GL01DB | 01 | MD | CARE 1ST BCBS | OTHER |