Provider Demographics
NPI:1013502137
Name:CEDRIC WILSON, LPC, LLC
Entity Type:Organization
Organization Name:CEDRIC WILSON, LPC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO & THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:CEDRIC
Authorized Official - Middle Name:
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:540-339-7674
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:443-604-5945
Mailing Address - Fax:540-339-7674
Practice Address - Street 1:3048 BRAMBLETON AVE SW
Practice Address - Street 2:
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24015-4404
Practice Address - Country:US
Practice Address - Phone:540-339-7674
Practice Address - Fax:540-685-0994
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-03-02
Last Update Date:2021-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health