Provider Demographics
NPI:1043753965
Name:WILSON, LUTANYA MICHELLE (LICSW, LCSW-C, LCSW)
Entity Type:Individual
Prefix:MISS
First Name:LUTANYA
Middle Name:MICHELLE
Last Name:WILSON
Suffix:
Gender:F
Credentials:LICSW, LCSW-C, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2905 MITCHELLVILLE RD STE 201
Mailing Address - Street 2:
Mailing Address - City:BOWIE
Mailing Address - State:MD
Mailing Address - Zip Code:20716-3989
Mailing Address - Country:US
Mailing Address - Phone:443-758-0333
Mailing Address - Fax:
Practice Address - Street 1:6216 OLD FRANCONIA RD STE B
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22310-3401
Practice Address - Country:US
Practice Address - Phone:443-758-0333
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-11-25
Last Update Date:2019-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCLC500801481041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical