Provider Demographics
NPI:1821515859
Name:WILSON, PAMELA ROSETTA
Entity Type:Individual
Prefix:
First Name:PAMELA
Middle Name:ROSETTA
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 1473
Mailing Address - Street 2:
Mailing Address - City:HOPEWELL
Mailing Address - State:VA
Mailing Address - Zip Code:23860-1473
Mailing Address - Country:US
Mailing Address - Phone:703-915-9526
Mailing Address - Fax:240-595-6187
Practice Address - Street 1:10408 COURTHOUSE RD
Practice Address - Street 2:
Practice Address - City:SPOTSYLVANIA
Practice Address - State:VA
Practice Address - Zip Code:22553-1712
Practice Address - Country:US
Practice Address - Phone:804-931-0660
Practice Address - Fax:240-595-6187
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-30
Last Update Date:2022-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
0717001457101YP2500X, 101YP2500X
VA0717001457106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist