Provider Demographics
NPI:1972989895
Name:DOCTOR, WILLIE DWAYNE JR (LCSW-C)
Entity type:Individual
Prefix:
First Name:WILLIE
Middle Name:DWAYNE
Last Name:DOCTOR
Suffix:JR
Gender:
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:PO BOX 6211
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MD
Mailing Address - Zip Code:21045-6211
Mailing Address - Country:US
Mailing Address - Phone:301-920-4514
Mailing Address - Fax:
Practice Address - Street 1:9002 PHILLIP DORSEY WAY
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MD
Practice Address - Zip Code:21045-5149
Practice Address - Country:US
Practice Address - Phone:301-920-4514
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-08-03
Last Update Date:2025-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD209331041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD608401000Medicaid