Provider Demographics
NPI:1306051313
Name:WILSON, MARY DEBORAH (PMHNP-BC)
Entity type:Individual
Prefix:MS
First Name:MARY
Middle Name:DEBORAH
Last Name:WILSON
Suffix:
Gender:F
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:DEBORAH
Other - Middle Name:
Other - Last Name:WILSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MS,RN, CRNP-BC
Mailing Address - Street 1:11022 NICHOLAS LN
Mailing Address - Street 2:UNIT 2 SUITE 1
Mailing Address - City:BERLIN
Mailing Address - State:MD
Mailing Address - Zip Code:21811-3352
Mailing Address - Country:US
Mailing Address - Phone:410-641-5190
Mailing Address - Fax:410-641-5463
Practice Address - Street 1:11022 NICHOLAS LN
Practice Address - Street 2:UNIT 2 SUITE 1
Practice Address - City:BERLIN
Practice Address - State:MD
Practice Address - Zip Code:21811-3353
Practice Address - Country:US
Practice Address - Phone:410-641-5190
Practice Address - Fax:410-641-5463
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-12
Last Update Date:2020-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR056757363L00000X, 363LG0600X, 364SP0809X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
No364SP0809XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health, Adult
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD609550001Medicaid
MD517251OtherOPTUM
MD346646OtherMANAGED HEALTH NET/TRICARE
MD259147-000OtherMAGELLAN BEHAVIORAL HEALTH
MD609550004Medicaid
MD499188OtherBEACON HEALTH OPTIONS
MD609550002Medicaid
MD7840093OtherAETNA
MDR968OtherCAREFIRST OF MARYLAND
MD742LMedicare PIN