Provider Demographics
NPI:1609580711
Name:WILSON, LAKEISHA (MS, LMSW)
Entity Type:Individual
Prefix:
First Name:LAKEISHA
Middle Name:
Last Name:WILSON
Suffix:
Gender:F
Credentials:MS, LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1028 MONDRIAN TER
Mailing Address - Street 2:
Mailing Address - City:SILVER SPRING
Mailing Address - State:MD
Mailing Address - Zip Code:20904-3269
Mailing Address - Country:US
Mailing Address - Phone:301-237-9661
Mailing Address - Fax:
Practice Address - Street 1:1028 MONDRIAN TER
Practice Address - Street 2:
Practice Address - City:SILVER SPRING
Practice Address - State:MD
Practice Address - Zip Code:20904-3269
Practice Address - Country:US
Practice Address - Phone:301-237-9661
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-12
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDG12901104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDG12901OtherLICENSE NUMBER