Provider Demographics
NPI:1255162111
Name:WILSON, DERRICK (MT)
Entity type:Individual
Prefix:
First Name:DERRICK
Middle Name:
Last Name:WILSON
Suffix:
Gender:M
Credentials:MT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:883 CLOPPER RD APT A4
Mailing Address - Street 2:
Mailing Address - City:GAITHERSBURG
Mailing Address - State:MD
Mailing Address - Zip Code:20878-4424
Mailing Address - Country:US
Mailing Address - Phone:518-421-7242
Mailing Address - Fax:
Practice Address - Street 1:2701 ONTARIO RD NW
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20009-2144
Practice Address - Country:US
Practice Address - Phone:202-299-9005
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-12
Last Update Date:2024-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCMT2457225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist