Provider Demographics
NPI:1922624154
Name:WILSON, CEDRIC
Entity Type:Individual
Prefix:
First Name:CEDRIC
Middle Name:
Last Name:WILSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2907 OAK CREST AVE SW
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24015-4609
Mailing Address - Country:US
Mailing Address - Phone:540-339-7674
Mailing Address - Fax:540-685-0994
Practice Address - Street 1:3959 ELECTRIC RD STE 330
Practice Address - Street 2:
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24018-4563
Practice Address - Country:US
Practice Address - Phone:540-339-7674
Practice Address - Fax:540-685-0994
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-23
Last Update Date:2023-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0701008867101Y00000X, 101YA0400X, 101YP2500X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1013502137OtherNPI2