Provider Demographics
NPI:1649742479
Name:WILSON, CRISTINA AMBOS
Entity Type:Individual
Prefix:MISS
First Name:CRISTINA
Middle Name:AMBOS
Last Name:WILSON
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 1:108 HOLLY WAY
Mailing Address - Street 2:
Mailing Address - City:PISMO BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:93449-3221
Mailing Address - Country:US
Mailing Address - Phone:805-904-6592
Mailing Address - Fax:805-904-6593
Practice Address - Street 1:108 HOLLY WAY
Practice Address - Street 2:
Practice Address - City:PISMO BEACH
Practice Address - State:CA
Practice Address - Zip Code:93449-3221
Practice Address - Country:US
Practice Address - Phone:805-904-6592
Practice Address - Fax:805-904-6593
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-18
Last Update Date:2018-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA405801964103TA0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TA0700XBehavioral Health & Social Service ProvidersPsychologistAdult Development & Aging