Healthcare Provider Details

I. General information

NPI: 1104976257
Provider Name (Legal Business Name): VALETA B WILSON LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/11/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

224 GREAT BRIDGE BLVD CHESAPEAKE COMM SERVICES BOARD
CHESAPEAKE VA
23320
US

IV. Provider business mailing address

PO BOX 1647 224 GREAT BRIDGE BLVD
CHESAPEAKE VA
23320
US

V. Phone/Fax

Practice location:
  • Phone: 757-547-9334
  • Fax: 757-819-6292
Mailing address:
  • Phone: 757-547-9334
  • Fax: 757-819-6292

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number0904006234
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: