Healthcare Provider Details

I. General information

NPI: 1215868807
Provider Name (Legal Business Name): TAMERA WILSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/25/2026
Last Update Date: 05/25/2026
Certification Date: 05/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16021 CONTINENTAL BLVD
SOUTH CHESTERFIELD VA
23834-5900
US

IV. Provider business mailing address

16021 CONTINENTAL BLVD
SOUTH CHESTERFIELD VA
23834-5900
US

V. Phone/Fax

Practice location:
  • Phone: 804-985-1060
  • Fax:
Mailing address:
  • Phone: 804-985-1060
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberT62573107
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: