Provider Demographics
NPI:1972162394
Name:WILSON, MISTY (LCSW-C)
Entity type:Individual
Prefix:
First Name:MISTY
Middle Name:
Last Name:WILSON
Suffix:
Gender:F
Credentials:LCSW-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1705 E WEST HWY APT 202
Mailing Address - Street 2:
Mailing Address - City:SILVER SPRING
Mailing Address - State:MD
Mailing Address - Zip Code:20910-3025
Mailing Address - Country:US
Mailing Address - Phone:401-390-4253
Mailing Address - Fax:
Practice Address - Street 1:1705 E WEST HWY APT 202
Practice Address - Street 2:
Practice Address - City:SILVER SPRING
Practice Address - State:MD
Practice Address - Zip Code:20910-3025
Practice Address - Country:US
Practice Address - Phone:401-390-4253
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-10
Last Update Date:2022-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD248631041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical