Provider Demographics
NPI:1689132557
Name:WILSON, LAELI SHARIFI (LCP)
Entity Type:Individual
Prefix:
First Name:LAELI
Middle Name:SHARIFI
Last Name:WILSON
Suffix:
Gender:F
Credentials:LCP
Other - Prefix:
Other - First Name:LAELI
Other - Middle Name:
Other - Last Name:SHARIFI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4320 PRINCE WILLIAM PKWY STE 109
Mailing Address - Street 2:
Mailing Address - City:WOODBRIDGE
Mailing Address - State:VA
Mailing Address - Zip Code:22192-8100
Mailing Address - Country:US
Mailing Address - Phone:703-680-4200
Mailing Address - Fax:
Practice Address - Street 1:4320 PRINCE WILLIAM PKWY STE 109
Practice Address - Street 2:
Practice Address - City:WOODBRIDGE
Practice Address - State:VA
Practice Address - Zip Code:22192-8100
Practice Address - Country:US
Practice Address - Phone:703-680-4200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-08
Last Update Date:2023-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
VA0810008217103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician