Provider Demographics
NPI:1053371195
Name:WILSON, ALEXANDER A (LCSW)
Entity type:Individual
Prefix:MR
First Name:ALEXANDER
Middle Name:A
Last Name:WILSON
Suffix:
Gender:M
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:PO BOX 292
Mailing Address - Street 2:
Mailing Address - City:STUDLEY
Mailing Address - State:VA
Mailing Address - Zip Code:23162-0292
Mailing Address - Country:US
Mailing Address - Phone:804-559-4566
Mailing Address - Fax:804-559-1449
Practice Address - Street 1:7494 LEE DAVIS RD STE 16D
Practice Address - Street 2:
Practice Address - City:MECHANICSVILLE
Practice Address - State:VA
Practice Address - Zip Code:23111-3607
Practice Address - Country:US
Practice Address - Phone:804-559-4566
Practice Address - Fax:804-559-1449
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-24
Last Update Date:2025-01-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0904001692104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010229324Medicaid
C09747OtherMEDICARE GROUP NUMBER
R58155Medicare UPIN