Basic Information
Provider Information | |||||||||
NPI: | 1942478839 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | CHRISTOPHERSEN | ||||||||
FirstName: | LYN | ||||||||
MiddleName: | M | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | LISAC | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 483 W SEED FARM RD | ||||||||
Address2: | GILA RIVER HU HU KAM MEMORIAL MEDICAL CENTER RHBA | ||||||||
City: | SACATON | ||||||||
State: | AZ | ||||||||
PostalCode: | 85247 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6025287151 | ||||||||
FaxNumber: | 6025281374 | ||||||||
Practice Location | |||||||||
Address1: | 483 W SEED FARM RD | ||||||||
Address2: | GILA RIVER HU HU KAM MEMORIAL MEDICAL CENTER RHBA | ||||||||
City: | SACATON | ||||||||
State: | AZ | ||||||||
PostalCode: | 85247 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6025287151 | ||||||||
FaxNumber: | 6025281374 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/14/2008 | ||||||||
LastUpdateDate: | 02/14/2008 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | LISAC 0751 | AZ | Y |   | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
ID Information
ID | Type | State | Issuer | Description | 346214 | 05 | AZ |   | MEDICAID |