Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 101YP1600X | Pastoral Counselor | LC5129 | MD |
Y | 101YP2500X | Professional Counselor | LC5129 | MD |
NPI | 1174773378 |
---|---|
Provider Name | Anita Wiley |
First Address | Waldorf, MD 20602-3801 |
Second Address | Waldorf, MD 20602-3801 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 24/09/2008 |
Last Update Date | 06/03/2016 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
58956180 | (05) | MD |