Provider Demographics
NPI:1790469377
Name:VAILOR, WYKENNA S (MHS, ADT)
Entity Type:Individual
Prefix:
First Name:WYKENNA
Middle Name:S
Last Name:VAILOR
Suffix:
Gender:F
Credentials:MHS, ADT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11100 BILLINGSLEY RD
Mailing Address - Street 2:
Mailing Address - City:WALDORF
Mailing Address - State:MD
Mailing Address - Zip Code:20602-3400
Mailing Address - Country:US
Mailing Address - Phone:240-754-6168
Mailing Address - Fax:
Practice Address - Street 1:11100 BILLINGSLEY RD
Practice Address - Street 2:
Practice Address - City:WALDORF
Practice Address - State:MD
Practice Address - Zip Code:20602-3400
Practice Address - Country:US
Practice Address - Phone:240-754-6168
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-14
Last Update Date:2023-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)