Provider Demographics
NPI:1386218196
Name:WILSON, DANIELLE E
Entity Type:Individual
Prefix:
First Name:DANIELLE
Middle Name:E
Last Name:WILSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7628 FAYVER AVE
Mailing Address - Street 2:
Mailing Address - City:NORFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23505-2408
Mailing Address - Country:US
Mailing Address - Phone:240-678-8627
Mailing Address - Fax:
Practice Address - Street 1:1106 CAMPOSTELLA RD
Practice Address - Street 2:
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23523-2104
Practice Address - Country:US
Practice Address - Phone:757-494-3850
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-17
Last Update Date:2021-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0813001152103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool