Provider Demographics
NPI:1083643720
Name:WILSON, VICTORIA ELAINE (LCSWC)
Entity type:Individual
Prefix:MS
First Name:VICTORIA
Middle Name:ELAINE
Last Name:WILSON
Suffix:
Gender:F
Credentials:LCSWC
Other - Prefix:
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Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 64515
Mailing Address - Street 2:SEVERNA PARK PROFESSIONAL COUNSELING CENTER
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21264-4515
Mailing Address - Country:US
Mailing Address - Phone:717-428-0552
Mailing Address - Fax:
Practice Address - Street 1:1110 BENFIELD BLVD SUITE H
Practice Address - Street 2:SEVERNA PARK PROFESSIONAL COUNSELING CENTER
Practice Address - City:MILLERSVILLE
Practice Address - State:MD
Practice Address - Zip Code:21108
Practice Address - Country:US
Practice Address - Phone:410-987-5048
Practice Address - Fax:410-987-4710
Is Sole Proprietor?:No
Enumeration Date:2006-07-03
Last Update Date:2016-07-22
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MD075901041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD243000200Medicaid
2W66OtherBCBS
MD243000200Medicaid