Healthcare Provider Details

I. General information

NPI: 1013021740
Provider Name (Legal Business Name): CHRISTY V WILSON LCSW, CDMS, CRC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/19/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

120 N BRYANT AVE STE A5
EDMOND OK
73034-6300
US

IV. Provider business mailing address

PO BOX 1729
NORMAN OK
73070-1729
US

V. Phone/Fax

Practice location:
  • Phone: 405-640-5270
  • Fax:
Mailing address:
  • Phone: 405-321-3499
  • Fax: 405-364-5379

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number1989
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: