Basic Information
Provider Information | |||||||||
NPI: | 1922515055 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | CHYKIRDA | ||||||||
FirstName: | CHRISTINA | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | LPC | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 41 CARILLON DR APT D | ||||||||
Address2: |   | ||||||||
City: | ROCKY HILL | ||||||||
State: | CT | ||||||||
PostalCode: | 060672541 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8604906283 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 150 N MAIN ST | ||||||||
Address2: |   | ||||||||
City: | MANCHESTER | ||||||||
State: | CT | ||||||||
PostalCode: | 060422086 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8605333434 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/10/2018 | ||||||||
LastUpdateDate: | 08/07/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 08/07/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | 004112 | CT | Y |   | Behavioral Health & Social Service Providers | Counselor | Professional |
No ID Information.