Provider Demographics
NPI:1447565205
Name:WEDLOCK, MARY D (BA)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:D
Last Name:WEDLOCK
Suffix:
Gender:F
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:4705A OLD POST RD
Mailing Address - Street 2:
Mailing Address - City:CHARLESTOWN
Mailing Address - State:RI
Mailing Address - Zip Code:02813-1819
Mailing Address - Country:US
Mailing Address - Phone:401-364-7705
Mailing Address - Fax:401-364-9104
Practice Address - Street 1:55 CHERRY LN
Practice Address - Street 2:
Practice Address - City:WAKEFIELD
Practice Address - State:RI
Practice Address - Zip Code:02879-3617
Practice Address - Country:US
Practice Address - Phone:401-789-1367
Practice Address - Fax:401-364-7705
Is Sole Proprietor?:No
Enumeration Date:2010-08-17
Last Update Date:2012-02-02
Deactivation Date:
Deactivation Code:
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Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health