Provider Demographics
NPI:1326875519
Name:WYSOCKI, ALICE (LGPC)
Entity type:Individual
Prefix:
First Name:ALICE
Middle Name:
Last Name:WYSOCKI
Suffix:
Gender:F
Credentials:LGPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:815 RITCHIE HWY STE 112
Mailing Address - Street 2:
Mailing Address - City:SEVERNA PARK
Mailing Address - State:MD
Mailing Address - Zip Code:21146-4192
Mailing Address - Country:US
Mailing Address - Phone:667-500-4556
Mailing Address - Fax:
Practice Address - Street 1:59 KATE WAGNER RD
Practice Address - Street 2:
Practice Address - City:WESTMINSTER
Practice Address - State:MD
Practice Address - Zip Code:21157-6957
Practice Address - Country:US
Practice Address - Phone:410-848-2500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-09-19
Last Update Date:2024-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLGP15631101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health