Healthcare Provider Details

I. General information

NPI: 1578737649
Provider Name (Legal Business Name): ALICE CHENEY WILSON AU.D., ABA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/18/2008
Last Update Date: 11/24/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19465 DEERFIELD AVE SUITE 201
LANSDOWNE VA
20176-1701
US

IV. Provider business mailing address

19465 DEERFIELD AVE SUITE 201
LANSDOWNE VA
20176-1701
US

V. Phone/Fax

Practice location:
  • Phone: 703-858-7620
  • Fax: 703-858-7657
Mailing address:
  • Phone: 703-858-7620
  • Fax: 703-858-7657

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code231H00000X
TaxonomyAudiologist
License Number2201001392
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code237600000X
TaxonomyAudiologist-Hearing Aid Fitter
License Number2101001768
License Number StateVA
# 3
Primary TaxonomyN
Taxonomy Code237700000X
TaxonomyHearing Instrument Specialist
License Number2101001768
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: