Provider Demographics
NPI:1073688677
Name:WILSON, CHRISTINE ALLENE (M EDPSYCH)
Entity Type:Individual
Prefix:
First Name:CHRISTINE
Middle Name:ALLENE
Last Name:WILSON
Suffix:
Gender:F
Credentials:M EDPSYCH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:417 N MAPLE ST
Mailing Address - Street 2:
Mailing Address - City:COLVILLE
Mailing Address - State:WA
Mailing Address - Zip Code:99114-3013
Mailing Address - Country:US
Mailing Address - Phone:509-690-0715
Mailing Address - Fax:
Practice Address - Street 1:417 N MAPLE ST
Practice Address - Street 2:
Practice Address - City:COLVILLE
Practice Address - State:WA
Practice Address - Zip Code:99114-3013
Practice Address - Country:US
Practice Address - Phone:509-690-0715
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-21
Last Update Date:2011-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALH00004755101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA907172Medicaid