Healthcare Provider Details

I. General information

NPI: 1386795250
Provider Name (Legal Business Name): LEON M WILSON LPC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/16/2007
Last Update Date: 01/22/2021
Certification Date: 01/22/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

307 LAFAYETTE BLVD STE 202
FREDERICKSBURG VA
22401-6079
US

IV. Provider business mailing address

PO BOX 297
HARTWOOD VA
22471-0297
US

V. Phone/Fax

Practice location:
  • Phone: 703-915-9526
  • Fax: 240-595-6187
Mailing address:
  • Phone: 703-915-9526
  • Fax: 240-595-6187

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number0701003698
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: