Provider Demographics
NPI:1356899546
Name:WILSON, LAGAIL JEANEAN (LCMFT)
Entity type:Individual
Prefix:MRS
First Name:LAGAIL
Middle Name:JEANEAN
Last Name:WILSON
Suffix:
Gender:F
Credentials:LCMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17604 PHELPS HILL LN
Mailing Address - Street 2:
Mailing Address - City:DERWOOD
Mailing Address - State:MD
Mailing Address - Zip Code:20855-1358
Mailing Address - Country:US
Mailing Address - Phone:913-963-7133
Mailing Address - Fax:844-375-0213
Practice Address - Street 1:15717 CRABBS BRANCH WAY STE 229
Practice Address - Street 2:
Practice Address - City:ROCKVILLE
Practice Address - State:MD
Practice Address - Zip Code:20855-6650
Practice Address - Country:US
Practice Address - Phone:301-637-2792
Practice Address - Fax:844-375-0213
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-15
Last Update Date:2020-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS2852106H00000X
KS2794106H00000X
MDLCM756106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS201229790AMedicaid