Provider Demographics
NPI:1992387534
Name:WILSON, CHARLES H IV (LMHP-R)
Entity Type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:H
Last Name:WILSON
Suffix:IV
Gender:M
Credentials:LMHP-R
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9355 TARTAN VIEW DR
Mailing Address - Street 2:
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22032-1207
Mailing Address - Country:US
Mailing Address - Phone:571-346-9437
Mailing Address - Fax:
Practice Address - Street 1:13400 EDGEMEADE RD
Practice Address - Street 2:
Practice Address - City:UPPER MARLBORO
Practice Address - State:MD
Practice Address - Zip Code:20772-8088
Practice Address - Country:US
Practice Address - Phone:301-358-0192
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-23
Last Update Date:2021-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0704013703101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor