Basic Information
| Provider Information | |||||||||
| NPI: | 1962605717 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WILSON | ||||||||
| FirstName: | CHRISTINE | ||||||||
| MiddleName: | |||||||||
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| Credential: | LMHC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 64 BLACK BASS BLVD | ||||||||
| Address2: | |||||||||
| City: | DEFUNIAK SPRINGS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 324338522 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8503330813 | ||||||||
| FaxNumber: | 8503330813 | ||||||||
| Practice Location | |||||||||
| Address1: | 5642 JONES ST | ||||||||
| Address2: | |||||||||
| City: | MILTON | ||||||||
| State: | FL | ||||||||
| PostalCode: | 325702304 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8506267779 | ||||||||
| FaxNumber: | 8506267171 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/08/2007 | ||||||||
| LastUpdateDate: | 01/09/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | MH8926 | FL | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.