Provider Demographics
NPI:1013225457
Name:WOOTEN, EDDYMIE (LCMFT)
Entity Type:Individual
Prefix:
First Name:EDDYMIE
Middle Name:
Last Name:WOOTEN
Suffix:
Gender:F
Credentials:LCMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8805 CHARM CT
Mailing Address - Street 2:
Mailing Address - City:BRANDYWINE
Mailing Address - State:MD
Mailing Address - Zip Code:20613-3010
Mailing Address - Country:US
Mailing Address - Phone:443-646-3907
Mailing Address - Fax:
Practice Address - Street 1:1910 TOWNE CENTRE BLVD STE 250
Practice Address - Street 2:
Practice Address - City:ANNAPOLIS
Practice Address - State:MD
Practice Address - Zip Code:21401-3599
Practice Address - Country:US
Practice Address - Phone:443-646-3907
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-20
Last Update Date:2020-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLCM388106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist