Provider Demographics
NPI:1821287178
Name:WANNON, MICHAEL NA (PHD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:NA
Last Name:WANNON
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5454 WISCONSIN AVE
Mailing Address - Street 2:SUITE 1215
Mailing Address - City:CHEVY CHASE
Mailing Address - State:MD
Mailing Address - Zip Code:20815-6901
Mailing Address - Country:US
Mailing Address - Phone:301-951-9488
Mailing Address - Fax:301-654-8571
Practice Address - Street 1:5454 WISCONSIN AVE
Practice Address - Street 2:SUITE 1215
Practice Address - City:CHEVY CHASE
Practice Address - State:MD
Practice Address - Zip Code:20815-6901
Practice Address - Country:US
Practice Address - Phone:301-951-9488
Practice Address - Fax:301-654-8571
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-22
Last Update Date:2007-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD3122103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical