Healthcare Provider Details

I. General information

NPI: 1144175225
Provider Name (Legal Business Name): CHRISTIE I WILSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/03/2026
Last Update Date: 03/03/2026
Certification Date: 03/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

29948 CUT OFF RD
CULDESAC ID
83524-6180
US

IV. Provider business mailing address

29948 CUT OFF RD
CULDESAC ID
83524-6180
US

V. Phone/Fax

Practice location:
  • Phone: 208-790-7267
  • Fax: 208-790-7267
Mailing address:
  • Phone: 208-790-7267
  • Fax: 208-790-7267

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: