Provider Demographics
NPI:1225003403
Name:WILSON, WILLETTA M (BLPC, LMFT, LPC, MAC)
Entity Type:Individual
Prefix:
First Name:WILLETTA
Middle Name:M
Last Name:WILSON
Suffix:
Gender:F
Credentials:BLPC, LMFT, LPC, MAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3775 FETTLER PARK DR
Mailing Address - Street 2:
Mailing Address - City:DUMFRIES
Mailing Address - State:VA
Mailing Address - Zip Code:22025-1946
Mailing Address - Country:US
Mailing Address - Phone:703-303-0039
Mailing Address - Fax:
Practice Address - Street 1:3775 FETTLER PARK DR
Practice Address - Street 2:
Practice Address - City:DUMFRIES
Practice Address - State:VA
Practice Address - Zip Code:22025-1946
Practice Address - Country:US
Practice Address - Phone:703-303-0039
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-21
Last Update Date:2016-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCPRC13727101YP2500X, 101Y00000X
DCLMFT000060106H00000X
VA6401007409101YP2500X
MI6401007409101Y00000X
NJ37LC00106600101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101Y00000XBehavioral Health & Social Service ProvidersCounselor