Provider Demographics
NPI:1982211322
Name:BRENDA BIVENS WILSON, LLC
Entity Type:Organization
Organization Name:BRENDA BIVENS WILSON, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BRENDA
Authorized Official - Middle Name:B
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:MS, LGPC
Authorized Official - Phone:410-336-2937
Mailing Address - Street 1:1726 BOLTON ST
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21217-4904
Mailing Address - Country:US
Mailing Address - Phone:443-525-0724
Mailing Address - Fax:
Practice Address - Street 1:1726 BOLTON ST
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21217-4904
Practice Address - Country:US
Practice Address - Phone:443-525-0724
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-09-29
Last Update Date:2021-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty