Provider Demographics
NPI:1871506527
Name:WILSON, RICHARD J (LPC)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:J
Last Name:WILSON
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 MEDICAL DR
Mailing Address - Street 2:2ND FLOOR
Mailing Address - City:HAMPTON
Mailing Address - State:VA
Mailing Address - Zip Code:23666-1765
Mailing Address - Country:US
Mailing Address - Phone:757-788-0092
Mailing Address - Fax:757-788-0969
Practice Address - Street 1:600 MEDICAL DR
Practice Address - Street 2:SUITE A
Practice Address - City:HAMPTON
Practice Address - State:VA
Practice Address - Zip Code:23666-1769
Practice Address - Country:US
Practice Address - Phone:757-788-0600
Practice Address - Fax:757-788-0932
Is Sole Proprietor?:No
Enumeration Date:2006-08-14
Last Update Date:2012-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0812000223101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA49-45573Medicaid
VA49-45573Medicaid