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General NPI Number Information
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NPI Number | 1215319637
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Entity Type | Individual
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Provider Name | CHRISTINE C WILSON LMT NCTMB
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Gender | Female
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Dates
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Enumeration Date | 06/22/2015
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Last Update Date | 06/22/2015
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Provider Practice Location Address
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Address Line | 9103 PHOENIX VILLAGE PKWY HEART CENTERED MASSAGE
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City | O FALLON
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State | MO
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Zip | 63368-4279
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Country | US
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Telephone | 630-338-5408
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Fax |
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Provider Business Mailing Address
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Address Line | 523 AVENTURA WAY
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City | SAINT PETERS
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State | MO
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Zip | 63376-5927
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Country | US
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Telephone | 630-338-5408
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225700000X
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Taxonomy Name | Massage Therapist
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License Number | 2014012307
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License Number State | MO
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Taxonomy #2
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Taxonomy Code | 225700000X
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Taxonomy Name | Massage Therapist
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License Number | 227014605
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License Number State | IL
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