MEDICARE: MISS CRISTINA AMBOS WILSON

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TA0700X	Adult Development & Aging Psychologist	405801964	CA

General Provider Information

NPI Number	:	1649742479
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MISS CRISTINA AMBOS WILSON

Provider Business Mailing Address
First Line	:	108 HOLLY WAY
Second Line	:
City	:	PISMO BEACH
State	:	CA
Zip	:	93449-3221
Country	:	US
Telephone Number	:	805-904-6592
Fax Number	:	805-904-6593

Provider Business Practice Location Address
First Line	:	108 HOLLY WAY
Second Line	:
City	:	PISMO BEACH
State	:	CA
Zip	:	93449-3221
Country	:	US
Telephone Number	:	805-904-6592
Fax Number	:	805-904-6593

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/18/2018
Last Update Date	:	12/18/2018

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Directions to “ MISS CRISTINA AMBOS WILSON ” Practice Location

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