Provider Demographics
NPI:1952062317
Name:WILSON, TRACEY LYNETTE
Entity Type:Individual
Prefix:
First Name:TRACEY
Middle Name:LYNETTE
Last Name:WILSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3611 CHAIN BRIDGE RD STE C
Mailing Address - Street 2:
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22030-3246
Mailing Address - Country:US
Mailing Address - Phone:703-397-8163
Mailing Address - Fax:
Practice Address - Street 1:3613 CHAIN BRIDGE RD STE D
Practice Address - Street 2:
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22030-3238
Practice Address - Country:US
Practice Address - Phone:703-397-8163
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-06
Last Update Date:2022-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor