Provider Demographics
NPI:1144427196
Name:WILSON, FREDERICK L (EDD)
Entity Type:Individual
Prefix:DR
First Name:FREDERICK
Middle Name:L
Last Name:WILSON
Suffix:
Gender:M
Credentials:EDD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2117 SMITH AVE
Mailing Address - Street 2:SUITE B
Mailing Address - City:CHESAPEAKE
Mailing Address - State:VA
Mailing Address - Zip Code:23320-2519
Mailing Address - Country:US
Mailing Address - Phone:757-937-3969
Mailing Address - Fax:757-548-1928
Practice Address - Street 1:2117 SMITH AVE
Practice Address - Street 2:SUITE B
Practice Address - City:CHESAPEAKE
Practice Address - State:VA
Practice Address - Zip Code:23320-2519
Practice Address - Country:US
Practice Address - Phone:757-937-3969
Practice Address - Fax:757-548-1928
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-02
Last Update Date:2023-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC6644101YM0800X
VA0701005950101YM0800X, 103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health