Healthcare Provider Details

I. General information

NPI: 1306162128
Provider Name (Legal Business Name): YOLANDA G WILSON LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/19/2010
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17579 WARWICK BLVD
NEWPORT NEWS VA
23603-1343
US

IV. Provider business mailing address

17579 WARWICK BLVD
NEWPORT NEWS VA
23603
US

V. Phone/Fax

Practice location:
  • Phone: 757-888-0400
  • Fax:
Mailing address:
  • Phone: 757-888-0400
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number66521
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: