Healthcare Provider Details

I. General information

NPI: 1033211602
Provider Name (Legal Business Name): WILSON CHAPMAN HURLEY LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/02/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13890 BRADDOCK RD SUITE 312
CENTREVILLE VA
20121-2435
US

IV. Provider business mailing address

5116 POMMEROY DR
FAIRFAX VA
22032-2806
US

V. Phone/Fax

Practice location:
  • Phone: 703-815-3800
  • Fax:
Mailing address:
  • Phone: 703-503-5487
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number0904001902
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: