Provider Demographics
NPI:1265501662
Name:WILSON, ELLEN CROSS (PHD)
Entity Type:Individual
Prefix:DR
First Name:ELLEN
Middle Name:CROSS
Last Name:WILSON
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 469
Mailing Address - Street 2:
Mailing Address - City:KERNERSVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27285-0469
Mailing Address - Country:US
Mailing Address - Phone:336-540-1065
Mailing Address - Fax:
Practice Address - Street 1:5587 GARDEN VILLAGE WAY STE A
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27410-8590
Practice Address - Country:US
Practice Address - Phone:336-540-1065
Practice Address - Fax:336-760-2149
Is Sole Proprietor?:No
Enumeration Date:2006-11-07
Last Update Date:2020-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCHSP-P # 0873103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC2819390BMedicare PIN
NC2819390AMedicare PIN