Healthcare Provider Details

I. General information

NPI: 1003580473
Provider Name (Legal Business Name): LAURA WILSON LCSW, MSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/09/2021
Last Update Date: 08/09/2021
Certification Date: 07/14/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16913 KNOBLEY RD
BURLINGTON WV
26710
US

IV. Provider business mailing address

539 NEW CREEK HWY
KEYSER WV
26726-8215
US

V. Phone/Fax

Practice location:
  • Phone: 304-289-3696
  • Fax:
Mailing address:
  • Phone: 304-813-2884
  • Fax: 304-788-2409

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberCP00943189
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: