Healthcare Provider Details

I. General information

NPI: 1154754828
Provider Name (Legal Business Name): ROBERT A WILSON LPC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/16/2013
Last Update Date: 08/16/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

40 COMMERCE DR STE B
MORGANTOWN WV
26501-3874
US

IV. Provider business mailing address

6 HOSPITAL PLZ
CLARKSBURG WV
26301-9316
US

V. Phone/Fax

Practice location:
  • Phone: 304-241-1708
  • Fax: 304-391-2054
Mailing address:
  • Phone: 304-623-5661
  • Fax: 304-623-2989

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number2044
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: