Provider Demographics
NPI:1811044381
Name:WILSON DALLAS, MERCEDES E
Entity Type:Individual
Prefix:DR
First Name:MERCEDES
Middle Name:E
Last Name:WILSON DALLAS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4906 SHARON RD
Mailing Address - Street 2:
Mailing Address - City:CAMP SPRINGS
Mailing Address - State:MD
Mailing Address - Zip Code:20748-2236
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:720 N SAINT ASAPH ST
Practice Address - Street 2:FOURTH FLOOR
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22314-1912
Practice Address - Country:US
Practice Address - Phone:703-838-6400
Practice Address - Fax:703-838-5070
Is Sole Proprietor?:No
Enumeration Date:2007-01-05
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0810001425103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA270291OtherAMERIGROUP
VI0025OtherCARE FIRST BCBS
VA008746A25OtherMEDICARE
VA188512OtherANTHEM
VA546001103002OtherTRICARE