Healthcare Provider Details

I. General information

NPI: 1013502137
Provider Name (Legal Business Name): CEDRIC WILSON, LPC, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/02/2021
Last Update Date: 03/02/2021
Certification Date: 03/02/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3048 BRAMBLETON AVE SW
ROANOKE VA
24015-4404
US

IV. Provider business mailing address

2907 OAK CREST AVE SW
ROANOKE VA
24015-4609
US

V. Phone/Fax

Practice location:
  • Phone: 540-339-7674
  • Fax: 540-685-0994
Mailing address:
  • Phone: 443-604-5945
  • Fax: 540-339-7674

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: CEDRIC WILSON
Title or Position: CEO & THERAPIST
Credential: LPC
Phone: 540-339-7674