Provider Demographics
NPI:1093180598
Name:WILSON-PAYNE, CHRYSTOL
Entity Type:Individual
Prefix:
First Name:CHRYSTOL
Middle Name:
Last Name:WILSON-PAYNE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:CHRYSTOL
Other - Middle Name:
Other - Last Name:WILSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:804 WEDGEWOOD WAY
Mailing Address - Street 2:
Mailing Address - City:SANDY SPRINGS
Mailing Address - State:GA
Mailing Address - Zip Code:30350-2067
Mailing Address - Country:US
Mailing Address - Phone:770-712-0224
Mailing Address - Fax:
Practice Address - Street 1:3937 HOLCOMB BRIDGE RD
Practice Address - Street 2:SUITES 200 AND 201
Practice Address - City:PEACHTREE CORNERS
Practice Address - State:GA
Practice Address - Zip Code:30092-2290
Practice Address - Country:US
Practice Address - Phone:678-736-4340
Practice Address - Fax:678-288-7836
Is Sole Proprietor?:Yes
Enumeration Date:2015-12-09
Last Update Date:2015-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA005359101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional