Provider Demographics
NPI:1093018483
Name:WILSON, SUSAN K (LPC)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:K
Last Name:WILSON
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:904 WYNNGATE DR
Mailing Address - Street 2:
Mailing Address - City:CHESAPEAKE
Mailing Address - State:VA
Mailing Address - Zip Code:23320-2958
Mailing Address - Country:US
Mailing Address - Phone:757-547-8664
Mailing Address - Fax:
Practice Address - Street 1:2473 N LANDING RD
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23456-3404
Practice Address - Country:US
Practice Address - Phone:757-385-4533
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-12-07
Last Update Date:2010-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0701003680101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1861562472Medicaid