Provider Demographics
NPI:1962605717
Name:WILSON, CHRISTINE (LMHC)
Entity type:Individual
Prefix:
First Name:CHRISTINE
Middle Name:
Last Name:WILSON
Suffix:
Gender:F
Credentials:LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:64 BLACK BASS BLVD
Mailing Address - Street 2:
Mailing Address - City:DEFUNIAK SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:32433-8522
Mailing Address - Country:US
Mailing Address - Phone:850-333-0813
Mailing Address - Fax:850-333-0813
Practice Address - Street 1:5642 JONES ST
Practice Address - Street 2:
Practice Address - City:MILTON
Practice Address - State:FL
Practice Address - Zip Code:32570-2304
Practice Address - Country:US
Practice Address - Phone:850-626-7779
Practice Address - Fax:850-626-7171
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-08
Last Update Date:2014-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH8926101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health