Healthcare Provider Details

I. General information

NPI: 1821515859
Provider Name (Legal Business Name): PAMELA ROSETTA WILSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/30/2017
Last Update Date: 06/24/2022
Certification Date: 06/24/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10408 COURTHOUSE RD
SPOTSYLVANIA VA
22553-1712
US

IV. Provider business mailing address

PO BOX 1473
HOPEWELL VA
23860-1473
US

V. Phone/Fax

Practice location:
  • Phone: 804-931-0660
  • Fax: 240-595-6187
Mailing address:
  • Phone: 703-915-9526
  • Fax: 240-595-6187

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number0717001457
License Number State
# 2
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number0717001457
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: