Provider Demographics
NPI:1184804601
Name:WIGGINS, MARY C (LPC)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:C
Last Name:WIGGINS
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:CATHERINE
Other - Last Name:WIGGINS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LPC
Mailing Address - Street 1:46179 WESTLAKE DR STE 340
Mailing Address - Street 2:
Mailing Address - City:STERLING
Mailing Address - State:VA
Mailing Address - Zip Code:20165-5874
Mailing Address - Country:US
Mailing Address - Phone:703-627-0616
Mailing Address - Fax:
Practice Address - Street 1:46179 WESTLAKE DR STE 340
Practice Address - Street 2:
Practice Address - City:STERLING
Practice Address - State:VA
Practice Address - Zip Code:20165-5874
Practice Address - Country:US
Practice Address - Phone:703-627-0616
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-13
Last Update Date:2023-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0701010221101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA30016188360002Medicaid