Healthcare Provider Details

I. General information

NPI: 1649742479
Provider Name (Legal Business Name): MISS CRISTINA AMBOS WILSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/18/2018
Last Update Date: 12/18/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

108 HOLLY WAY
PISMO BEACH CA
93449-3221
US

IV. Provider business mailing address

108 HOLLY WAY
PISMO BEACH CA
93449-3221
US

V. Phone/Fax

Practice location:
  • Phone: 805-904-6592
  • Fax: 805-904-6593
Mailing address:
  • Phone: 805-904-6592
  • Fax: 805-904-6593

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TA0700X
TaxonomyAdult Development & Aging Psychologist
License Number405801964
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: