Healthcare Provider Details

I. General information

NPI: 1194798157
Provider Name (Legal Business Name): CHRISTINA SARA WILSON PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/09/2006
Last Update Date: 03/10/2021
Certification Date: 03/01/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9000 COOMBS FARM RD STE 202
MORGANTOWN WV
26508-1150
US

IV. Provider business mailing address

279 GIBBONS ST
MORGANTOWN WV
26505-3557
US

V. Phone/Fax

Practice location:
  • Phone: 304-554-0504
  • Fax: 304-554-0505
Mailing address:
  • Phone: 304-276-0108
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number652
License Number StateWV
# 2
Primary TaxonomyY
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number652
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: