Basic Information
| Provider Information | |||||||||
| NPI: | 1538518964 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ANDERSON | ||||||||
| FirstName: | CHRISTINE | ||||||||
| MiddleName: | GRACE | ||||||||
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| Credential: | |||||||||
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| OtherLastName: | ANDERSON | ||||||||
| OtherFirstName: | CHRISTINE | ||||||||
| OtherMiddleName: | GRACE | ||||||||
| OtherNamePrefix: | MISS | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 625 SE MAYLOR ST | ||||||||
| Address2: | |||||||||
| City: | OAK HARBOR | ||||||||
| State: | WA | ||||||||
| PostalCode: | 982775413 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8052066465 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 231 SE BARRINGTON DR STE 203 | ||||||||
| Address2: | |||||||||
| City: | OAK HARBOR | ||||||||
| State: | WA | ||||||||
| PostalCode: | 982773200 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3602400022 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/07/2016 | ||||||||
| LastUpdateDate: | 06/07/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103K00000X | WA | Y | Behavioral Health & Social Service Providers | Behavioral Analyst |
ID Information
| ID | Type | State | Issuer | Description | 557863944 | 01 | WA | MEDICARE | OTHER |