Provider Demographics
NPI:1154064111
Name:WILKINSON, CORRINE
Entity Type:Individual
Prefix:
First Name:CORRINE
Middle Name:
Last Name:WILKINSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:750 CONCOURSE CIR STE 103-203
Mailing Address - Street 2:
Mailing Address - City:MIDDLE RIVER
Mailing Address - State:MD
Mailing Address - Zip Code:21220-2995
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1576 MERRITT BLVD STE 8
Practice Address - Street 2:
Practice Address - City:DUNDALK
Practice Address - State:MD
Practice Address - Zip Code:21222-2114
Practice Address - Country:US
Practice Address - Phone:443-530-6533
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-18
Last Update Date:2022-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLGP12540101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor