Healthcare Provider Details

I. General information

NPI: 1871506527
Provider Name (Legal Business Name): RICHARD J WILSON LPC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/14/2006
Last Update Date: 04/10/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 MEDICAL DR SUITE A
HAMPTON VA
23666-1769
US

IV. Provider business mailing address

300 MEDICAL DR 2ND FLOOR
HAMPTON VA
23666-1765
US

V. Phone/Fax

Practice location:
  • Phone: 757-788-0600
  • Fax: 757-788-0932
Mailing address:
  • Phone: 757-788-0092
  • Fax: 757-788-0969

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number0812000223
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: