Provider Demographics
NPI:1427225473
Name:WILSON, LAURA M (MS, LCPC)
Entity Type:Individual
Prefix:MISS
First Name:LAURA
Middle Name:M
Last Name:WILSON
Suffix:
Gender:F
Credentials:MS, LCPC
Other - Prefix:
Other - First Name:LAURA
Other - Middle Name:
Other - Last Name:BOOTH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCPC
Mailing Address - Street 1:16808 MOUNTAIN CLUB AVE
Mailing Address - Street 2:
Mailing Address - City:RAWLINGS
Mailing Address - State:MD
Mailing Address - Zip Code:21557-1016
Mailing Address - Country:US
Mailing Address - Phone:301-697-4222
Mailing Address - Fax:
Practice Address - Street 1:15820 MCMULLEN HWY SW APT A
Practice Address - Street 2:
Practice Address - City:CUMBERLAND
Practice Address - State:MD
Practice Address - Zip Code:21502-6618
Practice Address - Country:US
Practice Address - Phone:240-522-0885
Practice Address - Fax:410-885-4532
Is Sole Proprietor?:No
Enumeration Date:2008-05-09
Last Update Date:2022-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLC3190101YM0800X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD064578800Medicaid