Provider Demographics
NPI:1386795250
Name:WILSON, LEON M (LPC)
Entity type:Individual
Prefix:
First Name:LEON
Middle Name:M
Last Name:WILSON
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 297
Mailing Address - Street 2:
Mailing Address - City:HARTWOOD
Mailing Address - State:VA
Mailing Address - Zip Code:22471-0297
Mailing Address - Country:US
Mailing Address - Phone:703-915-9526
Mailing Address - Fax:240-595-6187
Practice Address - Street 1:307 LAFAYETTE BLVD STE 202
Practice Address - Street 2:
Practice Address - City:FREDERICKSBURG
Practice Address - State:VA
Practice Address - Zip Code:22401-6079
Practice Address - Country:US
Practice Address - Phone:703-915-9526
Practice Address - Fax:240-595-6187
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-16
Last Update Date:2021-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0701003698101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010090687Medicaid