Provider Demographics
NPI:1194798157
Name:WILSON, CHRISTINA SARA (PHD)
Entity type:Individual
Prefix:DR
First Name:CHRISTINA
Middle Name:SARA
Last Name:WILSON
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:279 GIBBONS ST
Mailing Address - Street 2:
Mailing Address - City:MORGANTOWN
Mailing Address - State:WV
Mailing Address - Zip Code:26505-3557
Mailing Address - Country:US
Mailing Address - Phone:304-276-0108
Mailing Address - Fax:
Practice Address - Street 1:9000 COOMBS FARM RD STE 202
Practice Address - Street 2:
Practice Address - City:MORGANTOWN
Practice Address - State:WV
Practice Address - Zip Code:26508-1150
Practice Address - Country:US
Practice Address - Phone:304-554-0504
Practice Address - Fax:304-554-0505
Is Sole Proprietor?:No
Enumeration Date:2006-02-09
Last Update Date:2021-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV652103TC0700X, 103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0164505000Medicaid
WV0164505000Medicaid
WVWI6026371Medicare ID - Type Unspecified