Provider Demographics
NPI:1679670848
Name:WILSON, KRISTIN A (MA, LPC, DTR)
Entity type:Individual
Prefix:MRS
First Name:KRISTIN
Middle Name:A
Last Name:WILSON
Suffix:
Gender:F
Credentials:MA, LPC, DTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:42 ENLOW PL
Mailing Address - Street 2:
Mailing Address - City:PENNSVILLE
Mailing Address - State:NJ
Mailing Address - Zip Code:08070-2031
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:710 S OLD MIDDLETOWN RD
Practice Address - Street 2:
Practice Address - City:MEDIA
Practice Address - State:PA
Practice Address - Zip Code:19063-5024
Practice Address - Country:US
Practice Address - Phone:610-619-9870
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPC002406101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional