Provider Demographics
NPI:1215337233
Name:WILSON, TESHANDRA (CMT)
Entity type:Individual
Prefix:
First Name:TESHANDRA
Middle Name:
Last Name:WILSON
Suffix:
Gender:F
Credentials:CMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6066 RED SQUIRREL PL
Mailing Address - Street 2:
Mailing Address - City:WALDORF
Mailing Address - State:MD
Mailing Address - Zip Code:20603-4443
Mailing Address - Country:US
Mailing Address - Phone:240-441-9608
Mailing Address - Fax:
Practice Address - Street 1:6066 RED SQUIRREL PL
Practice Address - Street 2:
Practice Address - City:WALDORF
Practice Address - State:MD
Practice Address - Zip Code:20603-4443
Practice Address - Country:US
Practice Address - Phone:240-441-9608
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-08-27
Last Update Date:2014-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDMT0084415171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor