Provider Demographics
NPI:1538379912
Name:WILSON, MICHAEL R (LCSW, BCD)
Entity type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:R
Last Name:WILSON
Suffix:
Gender:M
Credentials:LCSW, BCD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4516 BOONEDOCK RD
Mailing Address - Street 2:
Mailing Address - City:EARLYSVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:22936-2114
Mailing Address - Country:US
Mailing Address - Phone:434-979-0953
Mailing Address - Fax:
Practice Address - Street 1:24 RECTORY LN
Practice Address - Street 2:
Practice Address - City:STANARDSVILLE
Practice Address - State:VA
Practice Address - Zip Code:22973-2980
Practice Address - Country:US
Practice Address - Phone:434-985-5220
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-23
Last Update Date:2011-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA09040060281041C0700X
IL149-0030091041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA004945018Medicaid