Provider Demographics
NPI:1114155330
Name:WEISS, CHRISTINE DIEVENDORF (MA)
Entity Type:Individual
Prefix:MS
First Name:CHRISTINE
Middle Name:DIEVENDORF
Last Name:WEISS
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5400 HOLIDAY TER STE 200A
Mailing Address - Street 2:
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49009-2161
Mailing Address - Country:US
Mailing Address - Phone:269-520-0050
Mailing Address - Fax:269-520-0051
Practice Address - Street 1:5400 HOLIDAY TER STE 200A
Practice Address - Street 2:
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49009-2161
Practice Address - Country:US
Practice Address - Phone:269-520-0050
Practice Address - Fax:269-520-0051
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-25
Last Update Date:2023-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIL1393931103TC1900X
MI6401011020101YM0800X
MIL1556549101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounselingGroup - Single Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional