1346557337 NPI number — MISS KRISTIAN MONET WILSON LMHC

Table of content: MISS KRISTIAN MONET WILSON LMHC (NPI 1346557337)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1346557337 NPI number — MISS KRISTIAN MONET WILSON LMHC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WILSON
Provider First Name:
KRISTIAN
Provider Middle Name:
MONET
Provider Name Prefix Text:
MISS
Provider Name Suffix Text:
Provider Credential Text:
LMHC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
SAMUELS
Provider Other First Name:
KRISTIAN
Provider Other Middle Name:
MONET
Provider Other Name Prefix Text:
MISS
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1346557337
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/15/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
9034 BIGHORN TRL
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
JACKSONVILLE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32222-1672
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
904-597-6303
Provider Business Mailing Address Fax Number:
904-404-8351

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
9034 BIGHORN TRL
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
JACKSONVILLE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32222-1672
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
904-597-6303
Provider Business Practice Location Address Fax Number:
904-404-8351
Provider Enumeration Date:
09/12/2010

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YM0800X , with the licence number:  MH11336 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 012076600 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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