Basic Information
Provider Information | |||||||||
NPI: | 1316963457 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MARE | ||||||||
FirstName: | CHRISTINE | ||||||||
MiddleName: | L | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | AUD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | VAN DYKE | ||||||||
OtherFirstName: | CHRISTINE | ||||||||
OtherMiddleName: | L | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | AUD | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 6555 N CAMINO ARTURO | ||||||||
Address2: |   | ||||||||
City: | TUCSON | ||||||||
State: | AZ | ||||||||
PostalCode: | 857182013 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5207974780 | ||||||||
FaxNumber: | 5207974780 | ||||||||
Practice Location | |||||||||
Address1: | 3601 S 6TH AVE | ||||||||
Address2: | 5-126 | ||||||||
City: | TUCSON | ||||||||
State: | AZ | ||||||||
PostalCode: | 857230001 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5206291846 | ||||||||
FaxNumber: | 5206294707 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/14/2006 | ||||||||
LastUpdateDate: | 07/08/2007 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 231H00000X | DA1309 | AZ | X |   | Speech, Language and Hearing Service Providers | Audiologist |   | 237600000X | DA1309 | AZ | X |   | Speech, Language and Hearing Service Providers | Audiologist-Hearing Aid Fitter |   |
ID Information
ID | Type | State | Issuer | Description | 372475 | 05 | AZ |   | MEDICAID |