Provider Demographics
NPI:1558514778
Name:WILSON, LORI
Entity Type:Individual
Prefix:
First Name:LORI
Middle Name:
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:PO BOX 3060
Mailing Address - Street 2:
Mailing Address - City:PETERSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:23805-3060
Mailing Address - Country:US
Mailing Address - Phone:804-733-6875
Mailing Address - Fax:804-861-5625
Practice Address - Street 1:350 POPLAR DR
Practice Address - Street 2:
Practice Address - City:PETERSBURG
Practice Address - State:VA
Practice Address - Zip Code:23805-9367
Practice Address - Country:US
Practice Address - Phone:804-733-6875
Practice Address - Fax:804-861-5625
Is Sole Proprietor?:No
Enumeration Date:2008-10-31
Last Update Date:2008-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA09040067501041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical