Provider Demographics
NPI:1598125155
Name:WILKS, LISA (MA, LPC, LCPC)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:WILKS
Suffix:
Gender:F
Credentials:MA, LPC, LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1300 MERCANTILE LN
Mailing Address - Street 2:SUITE 100-M
Mailing Address - City:LARGO
Mailing Address - State:MD
Mailing Address - Zip Code:20774-5327
Mailing Address - Country:US
Mailing Address - Phone:202-600-1403
Mailing Address - Fax:
Practice Address - Street 1:1300 MERCANTILE LN STE 100M
Practice Address - Street 2:
Practice Address - City:LARGO
Practice Address - State:MD
Practice Address - Zip Code:20774-5390
Practice Address - Country:US
Practice Address - Phone:202-600-1403
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-25
Last Update Date:2019-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCPRC14749101Y00000X, 101YM0800X, 101YP2500X
MDLC7708101Y00000X, 101YM0800X, 101YP2500X
101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDLC7708OtherLCPC