Provider Demographics
NPI:1801206032
Name:WILSON, KRISTINA MARIE (LMSW)
Entity Type:Individual
Prefix:MRS
First Name:KRISTINA
Middle Name:MARIE
Last Name:WILSON
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1450 S LAPEER RD
Mailing Address - Street 2:
Mailing Address - City:OXFORD
Mailing Address - State:MI
Mailing Address - Zip Code:48371-6108
Mailing Address - Country:US
Mailing Address - Phone:248-524-8801
Mailing Address - Fax:
Practice Address - Street 1:1450 S LAPEER RD
Practice Address - Street 2:
Practice Address - City:OXFORD
Practice Address - State:MI
Practice Address - Zip Code:48371-6108
Practice Address - Country:US
Practice Address - Phone:248-524-8801
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-04-28
Last Update Date:2017-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6801096413104100000X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker