Provider Demographics
NPI:1710441290
Name:LLERENA, WILSON A (LGMFT)
Entity Type:Individual
Prefix:
First Name:WILSON
Middle Name:A
Last Name:LLERENA
Suffix:
Gender:M
Credentials:LGMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:319 W PATRICK ST
Mailing Address - Street 2:
Mailing Address - City:FREDERICK
Mailing Address - State:MD
Mailing Address - Zip Code:21701-4855
Mailing Address - Country:US
Mailing Address - Phone:301-640-5702
Mailing Address - Fax:443-331-4441
Practice Address - Street 1:319 W PATRICK ST
Practice Address - Street 2:
Practice Address - City:FREDERICK
Practice Address - State:MD
Practice Address - Zip Code:21701-4855
Practice Address - Country:US
Practice Address - Phone:301-640-5702
Practice Address - Fax:443-331-4441
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-29
Last Update Date:2024-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLCM811106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDLGM712Medicaid