Provider Demographics
NPI:1457121469
Name:WILT, JUSTIN (PMHNP)
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:
Last Name:WILT
Suffix:
Gender:M
Credentials:PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4635 FOXVILLE RD
Mailing Address - Street 2:
Mailing Address - City:SABILLASVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:21780-8510
Mailing Address - Country:US
Mailing Address - Phone:240-367-6331
Mailing Address - Fax:
Practice Address - Street 1:4635 FOXVILLE RD
Practice Address - Street 2:
Practice Address - City:SABILLASVILLE
Practice Address - State:MD
Practice Address - Zip Code:21780-8510
Practice Address - Country:US
Practice Address - Phone:240-367-6331
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-02
Last Update Date:2024-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD2023193496363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty