Basic Information
| Provider Information | |||||||||
| NPI: | 1700298924 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CHRISTENSON | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | LCSW | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 1387 | ||||||||
| Address2: | |||||||||
| City: | HAYDEN | ||||||||
| State: | ID | ||||||||
| PostalCode: | 838351387 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2084150299 | ||||||||
| FaxNumber: | 2086252070 | ||||||||
| Practice Location | |||||||||
| Address1: | 2205 IRONWOOD PL | ||||||||
| Address2: | STE A/B | ||||||||
| City: | COEUR D ALENE | ||||||||
| State: | ID | ||||||||
| PostalCode: | 838142785 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2086648347 | ||||||||
| FaxNumber: | 2086649217 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/22/2014 | ||||||||
| LastUpdateDate: | 01/18/2019 | ||||||||
| 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 | 104100000X | LMSW 1513 | ID | N | Behavioral Health & Social Service Providers | Social Worker | 1041C0700X | 36902 | ID | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 623468HNFS | 01 | ID | PAYER ID | OTHER |