Provider Demographics
NPI:1003398876
Name:FENNER, CHRISTOPHER JOHN
Entity Type:Individual
Prefix:
First Name:CHRISTOPHER
Middle Name:JOHN
Last Name:FENNER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19 GLEN OAK DR
Mailing Address - Street 2:
Mailing Address - City:ENFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06082-2603
Mailing Address - Country:US
Mailing Address - Phone:860-803-7468
Mailing Address - Fax:
Practice Address - Street 1:367 PINE ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MA
Practice Address - Zip Code:01105-1930
Practice Address - Country:US
Practice Address - Phone:413-372-9871
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-29
Last Update Date:2018-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health