Provider Demographics
NPI:1083258107
Name:WILKERSON, MARK (PHD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:
Last Name:WILKERSON
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:DR
Other - First Name:MARK
Other - Middle Name:
Other - Last Name:WILKERSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MARK WILKERSON, PHD
Mailing Address - Street 1:4655 PINTO CT
Mailing Address - Street 2:
Mailing Address - City:ELLICOTT CITY
Mailing Address - State:MD
Mailing Address - Zip Code:21043-6416
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4655 PINTO CT
Practice Address - Street 2:
Practice Address - City:ELLICOTT CITY
Practice Address - State:MD
Practice Address - Zip Code:21043-6416
Practice Address - Country:US
Practice Address - Phone:215-520-6774
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-31
Last Update Date:2023-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD101YM0800X, 103TS0200X
MDLBA710103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Multi-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchoolGroup - Multi-Specialty