Provider Demographics
NPI:1033877618
Name:WILSON, DEVETTA SHAUNTA (LCPC)
Entity Type:Individual
Prefix:
First Name:DEVETTA
Middle Name:SHAUNTA
Last Name:WILSON
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:414 HOWARD MANOR DR
Mailing Address - Street 2:
Mailing Address - City:GLEN BURNIE
Mailing Address - State:MD
Mailing Address - Zip Code:21060-8260
Mailing Address - Country:US
Mailing Address - Phone:443-591-0202
Mailing Address - Fax:
Practice Address - Street 1:6030 MARSHALEE DR STE M114
Practice Address - Street 2:
Practice Address - City:ELKRIDGE
Practice Address - State:MD
Practice Address - Zip Code:21075-5987
Practice Address - Country:US
Practice Address - Phone:443-591-0202
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-01
Last Update Date:2024-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLC14542101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional