Provider Demographics
NPI:1922100262
Name:WILSON, SUSAN M (LPC)
Entity Type:Individual
Prefix:MRS
First Name:SUSAN
Middle Name:M
Last Name:WILSON
Suffix:
Gender:F
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:PO BOX 11991
Mailing Address - Street 2:
Mailing Address - City:LYNCHBURG
Mailing Address - State:VA
Mailing Address - Zip Code:24506-1991
Mailing Address - Country:US
Mailing Address - Phone:434-847-8300
Mailing Address - Fax:434-847-8962
Practice Address - Street 1:2616 LANGHORNE RD
Practice Address - Street 2:STE 1
Practice Address - City:LYNCHBURG
Practice Address - State:VA
Practice Address - Zip Code:24501-1604
Practice Address - Country:US
Practice Address - Phone:434-847-8300
Practice Address - Fax:434-847-8962
Is Sole Proprietor?:No
Enumeration Date:2006-09-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0701002848101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA236395OtherANTHEM
473073OtherVALUE OPTIONS