Provider Demographics
NPI:1912209297
Name:WILSON, KRISTIE LYNN
Entity Type:Individual
Prefix:
First Name:KRISTIE
Middle Name:LYNN
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 1:2 GREGLEN AVE
Mailing Address - Street 2:PMB#83
Mailing Address - City:NANTUCKET
Mailing Address - State:MA
Mailing Address - Zip Code:02554-2830
Mailing Address - Country:US
Mailing Address - Phone:508-257-6112
Mailing Address - Fax:
Practice Address - Street 1:20 VESPER LN
Practice Address - Street 2:L-1
Practice Address - City:NANTUCKET
Practice Address - State:MA
Practice Address - Zip Code:02554-4394
Practice Address - Country:US
Practice Address - Phone:508-228-2689
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-11-19
Last Update Date:2010-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor