Provider Demographics
NPI:1659819548
Name:GARY N WILKERSON
Entity Type:Organization
Organization Name:GARY N WILKERSON
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COUNSELOR
Authorized Official - Prefix:
Authorized Official - First Name:GARY
Authorized Official - Middle Name:N
Authorized Official - Last Name:WILKERSON
Authorized Official - Suffix:
Authorized Official - Credentials:LSATP
Authorized Official - Phone:267-258-3894
Mailing Address - Street 1:PO BOX 494
Mailing Address - Street 2:
Mailing Address - City:ONANCOCK
Mailing Address - State:VA
Mailing Address - Zip Code:23417-0494
Mailing Address - Country:US
Mailing Address - Phone:267-258-3840
Mailing Address - Fax:
Practice Address - Street 1:3217 COMMANDER SHEPARD BLVD
Practice Address - Street 2:
Practice Address - City:HAMPTON
Practice Address - State:VA
Practice Address - Zip Code:23666
Practice Address - Country:US
Practice Address - Phone:757-215-8039
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-02-10
Last Update Date:2017-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0718000262251S00000X
DE0000066251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health