Basic Information
| Provider Information | |||||||||
| NPI: | 1740618982 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DETROIS | ||||||||
| FirstName: | CHRISTINE | ||||||||
| MiddleName: | ALEXANDRA | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | QMHA DT | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | PRIORE | ||||||||
| OtherFirstName: | CHRISTINE | ||||||||
| OtherMiddleName: | ALEXANDRA | ||||||||
| OtherNamePrefix: | MS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | QMHA DT | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 821 SAGINAW ST S | ||||||||
| Address2: | |||||||||
| City: | SALEM | ||||||||
| State: | OR | ||||||||
| PostalCode: | 973024121 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5035894046 | ||||||||
| FaxNumber: | 5034800484 | ||||||||
| Practice Location | |||||||||
| Address1: | 821 SAGINAW ST S | ||||||||
| Address2: | |||||||||
| City: | SALEM | ||||||||
| State: | OR | ||||||||
| PostalCode: | 973024121 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5035894046 | ||||||||
| FaxNumber: | 5034800484 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/25/2013 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
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| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251300000X | IL | N | Agencies | Local Education Agency (LEA) | 222Q00000X | IL | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Developmental Therapist |
ID Information
| ID | Type | State | Issuer | Description | 1740618982 | 05 | OR | MEDICAID |