Provider Demographics
NPI:1144887936
Name:WILSON DE MEDINA, CHRISTINE BETH (MS,LLP)
Entity type:Individual
Prefix:
First Name:CHRISTINE
Middle Name:BETH
Last Name:WILSON DE MEDINA
Suffix:
Gender:F
Credentials:MS,LLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17719 ODYSSEY
Mailing Address - Street 2:
Mailing Address - City:BELLEVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48111-9152
Mailing Address - Country:US
Mailing Address - Phone:248-943-6151
Mailing Address - Fax:
Practice Address - Street 1:W-4111 ANDOVER ROAD
Practice Address - Street 2:
Practice Address - City:BLOOMFIELD HILLS
Practice Address - State:MI
Practice Address - Zip Code:48302
Practice Address - Country:US
Practice Address - Phone:248-290-5400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-28
Last Update Date:2019-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIL915934103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist