Healthcare Provider Details

I. General information

NPI: 1518246289
Provider Name (Legal Business Name): JOHN EDWARD WILSON L.P.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/11/2011
Last Update Date: 05/08/2020
Certification Date: 05/08/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1241 N MAIN ST
HARRISONBURG VA
22802
US

IV. Provider business mailing address

1241 N MAIN ST
HARRISONBURG VA
22802-4632
US

V. Phone/Fax

Practice location:
  • Phone: 540-434-1941
  • Fax: 540-434-1791
Mailing address:
  • Phone: 540-434-1941
  • Fax: 540-434-0132

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number0717000167
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number0701002027
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: