Provider Demographics
NPI:1588280424
Name:WILSON, DOMONIQUE ASHLEIGH-NICOLE (LPC)
Entity type:Individual
Prefix:MS
First Name:DOMONIQUE
Middle Name:ASHLEIGH-NICOLE
Last Name:WILSON
Suffix:
Gender:F
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 2922
Mailing Address - Street 2:
Mailing Address - City:GLEN ALLEN
Mailing Address - State:VA
Mailing Address - Zip Code:23058-2922
Mailing Address - Country:US
Mailing Address - Phone:434-414-4555
Mailing Address - Fax:
Practice Address - Street 1:11221 ARBOR CREEK DR APT 436
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23233-0206
Practice Address - Country:US
Practice Address - Phone:434-414-4555
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-16
Last Update Date:2021-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0701009434101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional