Provider Demographics
NPI:1497940225
Name:WILDGOOSE, JOYCELYN (PHD)
Entity Type:Individual
Prefix:DR
First Name:JOYCELYN
Middle Name:
Last Name:WILDGOOSE
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:58 MILLARD CT
Mailing Address - Street 2:
Mailing Address - City:STERLING
Mailing Address - State:VA
Mailing Address - Zip Code:20165-6018
Mailing Address - Country:US
Mailing Address - Phone:703-433-2301
Mailing Address - Fax:703-433-2302
Practice Address - Street 1:58 MILLARD CT
Practice Address - Street 2:
Practice Address - City:STERLING
Practice Address - State:VA
Practice Address - Zip Code:20165-6018
Practice Address - Country:US
Practice Address - Phone:703-433-2301
Practice Address - Fax:703-433-2302
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-14
Last Update Date:2007-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0810000031103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical