Healthcare Provider Details

I. General information

NPI: 1245166081
Provider Name (Legal Business Name): VERONA DENISE WILBORN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/19/2026
Last Update Date: 07/13/2026
Certification Date: 07/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3915 BLENHEIM BLVD STE 23A
FAIRFAX VA
22030-2432
US

IV. Provider business mailing address

5249 BEACHMERE TER
CHESTER VA
23831-6583
US

V. Phone/Fax

Practice location:
  • Phone: 804-731-7699
  • Fax: 703-552-2037
Mailing address:
  • Phone: 804-731-7699
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number0704019057
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: