Provider Demographics
NPI:1922543370
Name:WILSON, CHRISTINA M (LMSW-CC)
Entity Type:Individual
Prefix:
First Name:CHRISTINA
Middle Name:M
Last Name:WILSON
Suffix:
Gender:F
Credentials:LMSW-CC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 SOUTHBOROUGH DR
Mailing Address - Street 2:SUITE 201
Mailing Address - City:SOUTH PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04106-6914
Mailing Address - Country:US
Mailing Address - Phone:207-661-2018
Mailing Address - Fax:207-661-2033
Practice Address - Street 1:474 MAIN ST
Practice Address - Street 2:
Practice Address - City:SPRINGVALE
Practice Address - State:ME
Practice Address - Zip Code:04083-1409
Practice Address - Country:US
Practice Address - Phone:207-324-1500
Practice Address - Fax:207-490-5263
Is Sole Proprietor?:No
Enumeration Date:2016-12-21
Last Update Date:2016-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEMC15221104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker