Provider Demographics
NPI:1609910348
Name:WILSON, KRISTINA (LICSW)
Entity Type:Individual
Prefix:
First Name:KRISTINA
Middle Name:
Last Name:WILSON
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:614 NASHUA ST
Mailing Address - Street 2:PMB 173
Mailing Address - City:MILFORD
Mailing Address - State:NH
Mailing Address - Zip Code:03055-4943
Mailing Address - Country:US
Mailing Address - Phone:603-672-6279
Mailing Address - Fax:
Practice Address - Street 1:15 UNION ST
Practice Address - Street 2:
Practice Address - City:MILFORD
Practice Address - State:NH
Practice Address - Zip Code:03055-4875
Practice Address - Country:US
Practice Address - Phone:603-672-6279
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-16
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH7401041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH40421090Medicaid