Provider Demographics
NPI:1346755345
Name:WESLEY, CHRISTINA SIDERS
Entity Type:Individual
Prefix:
First Name:CHRISTINA
Middle Name:SIDERS
Last Name:WESLEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7448 N LAFAYETTE ST
Mailing Address - Street 2:
Mailing Address - City:DEARBORN HEIGHTS
Mailing Address - State:MI
Mailing Address - Zip Code:48127-1759
Mailing Address - Country:US
Mailing Address - Phone:248-890-1025
Mailing Address - Fax:
Practice Address - Street 1:315 N CENTER ST
Practice Address - Street 2:
Practice Address - City:NORTHVILLE
Practice Address - State:MI
Practice Address - Zip Code:48167-1277
Practice Address - Country:US
Practice Address - Phone:313-656-4052
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-12
Last Update Date:2017-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301017325103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty