Provider Demographics
NPI:1609307040
Name:WOOTEN, PHYLICIA (LCPC)
Entity Type:Individual
Prefix:
First Name:PHYLICIA
Middle Name:
Last Name:WOOTEN
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14640 GALLANT LN
Mailing Address - Street 2:
Mailing Address - City:WALDORF
Mailing Address - State:MD
Mailing Address - Zip Code:20601-5509
Mailing Address - Country:US
Mailing Address - Phone:513-720-7447
Mailing Address - Fax:
Practice Address - Street 1:5510 REGENCY PLACE SUITE 203
Practice Address - Street 2:
Practice Address - City:WHITE PLAINS
Practice Address - State:MD
Practice Address - Zip Code:20695
Practice Address - Country:US
Practice Address - Phone:240-419-2556
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-03-27
Last Update Date:2020-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCLGPC00235101YP2500X
MDLC10320101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional