Provider Demographics
NPI:1972130037
Name:WILSON, BRENDA LOUISE (LCSW)
Entity type:Individual
Prefix:MS
First Name:BRENDA
Middle Name:LOUISE
Last Name:WILSON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1461 GLENSIDE GRN
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTESVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:22901-0658
Mailing Address - Country:US
Mailing Address - Phone:434-249-8240
Mailing Address - Fax:
Practice Address - Street 1:1008 E JEFFERSON ST
Practice Address - Street 2:
Practice Address - City:CHARLOTTESVILLE
Practice Address - State:VA
Practice Address - Zip Code:22902-5328
Practice Address - Country:US
Practice Address - Phone:434-249-8240
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-26
Last Update Date:2020-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA09040012161041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical