Provider Demographics
NPI:1639155583
Name:WILSON, RICHARD WILLIAM (LPC LMFT)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:WILLIAM
Last Name:WILSON
Suffix:
Gender:M
Credentials:LPC LMFT
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 35395
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23235-0395
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4914 RADFORD AVE
Practice Address - Street 2:STE 207
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23230-3538
Practice Address - Country:US
Practice Address - Phone:804-257-9556
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-21
Last Update Date:2008-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0701003716101Y00000X
VA0717001088106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA181219OtherBCBS
VA498920OtherVALUEOPTIONS
VAO81645MOtherOPTIMA
VA182885OtherBCBS
VA74653000OtherMAGELLAN
VA010203163Medicaid
VA324642OtherTRICARE