1639155583 NPI number — DR. RICHARD WILLIAM WILSON LPC LMFT

Table of content: DR. RICHARD WILLIAM WILSON LPC LMFT (NPI 1639155583)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1639155583 NPI number — DR. RICHARD WILLIAM WILSON LPC LMFT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WILSON
Provider First Name:
RICHARD
Provider Middle Name:
WILLIAM
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
LPC LMFT
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1639155583
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/26/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 35395
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
RICHMOND
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
23235-0395
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4914 RADFORD AVE
Provider Second Line Business Practice Location Address:
STE 207
Provider Business Practice Location Address City Name:
RICHMOND
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
23230-3538
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
804-257-9556
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/21/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101Y00000X , with the licence number:  0701003716 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 106H00000X , with the licence number: 0717001088 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 181219 . This is a "BCBS" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 498920 . This is a "VALUEOPTIONS" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: O81645M . This is a "OPTIMA" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 182885 . This is a "BCBS" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 74653000 . This is a "MAGELLAN" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 010203163 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 324642 . This is a "TRICARE" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".




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