Provider Demographics
NPI:1992380679
Name:WILSON, STEPHANIE LOUISE (LMFT)
Entity Type:Individual
Prefix:MRS
First Name:STEPHANIE
Middle Name:LOUISE
Last Name:WILSON
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6010 W BROAD ST STE 103
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23230-2215
Mailing Address - Country:US
Mailing Address - Phone:804-282-1863
Mailing Address - Fax:
Practice Address - Street 1:6010 W BROAD ST STE 103
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23230-2215
Practice Address - Country:US
Practice Address - Phone:804-282-1863
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-14
Last Update Date:2021-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0717001541106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist