Provider Demographics
NPI:1427536580
Name:WILSON, BRIAN
Entity Type:Individual
Prefix:MR
First Name:BRIAN
Middle Name:
Last Name:WILSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5136 WOOLVERTON AVE
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21215-5135
Mailing Address - Country:US
Mailing Address - Phone:410-967-6873
Mailing Address - Fax:
Practice Address - Street 1:5136 WOOLVERTON AVE
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21215-5135
Practice Address - Country:US
Practice Address - Phone:410-967-6873
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-01
Last Update Date:2018-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD18275104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Single Specialty