Provider Demographics
NPI:1619037967
Name:WILDING JONES, LAURA (PSYD)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:
Last Name:WILDING JONES
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:131 PARK ST NE
Mailing Address - Street 2:3RD FLOOR, SUITE B
Mailing Address - City:VIENNA
Mailing Address - State:VA
Mailing Address - Zip Code:22180-4641
Mailing Address - Country:US
Mailing Address - Phone:703-408-3772
Mailing Address - Fax:
Practice Address - Street 1:131 PARK ST NE
Practice Address - Street 2:3RD FLOOR, SUITE B
Practice Address - City:VIENNA
Practice Address - State:VA
Practice Address - Zip Code:22180-4641
Practice Address - Country:US
Practice Address - Phone:703-408-3772
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-09
Last Update Date:2013-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCPSY1000295103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
G57100Medicare UPIN