Provider Demographics
NPI:1730725375
Name:WILSON, SAMMY
Entity type:Individual
Prefix:
First Name:SAMMY
Middle Name:
Last Name:WILSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3628 MINE RD STE D
Mailing Address - Street 2:
Mailing Address - City:FREDERICKSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:22408-0224
Mailing Address - Country:US
Mailing Address - Phone:512-262-8107
Mailing Address - Fax:
Practice Address - Street 1:3628 MINE RD STE D
Practice Address - Street 2:
Practice Address - City:FREDERICKSBURG
Practice Address - State:VA
Practice Address - Zip Code:22408-0224
Practice Address - Country:US
Practice Address - Phone:512-262-8107
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-19
Last Update Date:2019-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No133NN1002XDietary & Nutritional Service ProvidersNutritionistNutrition, Education
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
No174400000XOther Service ProvidersSpecialist
No1744R1102XOther Service ProvidersSpecialistResearch Study
No174H00000XOther Service ProvidersHealth Educator
No251B00000XAgenciesCase Management
No251K00000XAgenciesPublic Health or Welfare
No253Z00000XAgenciesIn Home Supportive Care
No261Q00000XAmbulatory Health Care FacilitiesClinic/Center
No344600000XTransportation ServicesTaxi