Basic Information
| Provider Information | |||||||||
| NPI: | 1801233937 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WILSON | ||||||||
| FirstName: | CHRISTINA | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | LQP, MSW, LCSW, LCAS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2670 DURHAM CHAPEL HILL BLVD | ||||||||
| Address2: | |||||||||
| City: | DURHAM | ||||||||
| State: | NC | ||||||||
| PostalCode: | 277072829 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9192519001 | ||||||||
| FaxNumber: | 9192519010 | ||||||||
| Practice Location | |||||||||
| Address1: | 2670 DURHAM CHAPEL HILL BLVD | ||||||||
| Address2: | |||||||||
| City: | DURHAM | ||||||||
| State: | NC | ||||||||
| PostalCode: | 277072829 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9192519001 | ||||||||
| FaxNumber: | 9192519008 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/30/2013 | ||||||||
| LastUpdateDate: | 03/07/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | C009526 | NC | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical | 101YA0400X | LCAS - 20100 | NC | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.