Provider Demographics
NPI:1114204252
Name:BEATTY, CHRISTOPHER WILLIAM (OTR)
Entity Type:Individual
Prefix:
First Name:CHRISTOPHER
Middle Name:WILLIAM
Last Name:BEATTY
Suffix:
Gender:M
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1817 ROSE ST
Mailing Address - Street 2:
Mailing Address - City:BERKELEY
Mailing Address - State:CA
Mailing Address - Zip Code:94703-1117
Mailing Address - Country:US
Mailing Address - Phone:411-960-2723
Mailing Address - Fax:
Practice Address - Street 1:1817 ROSE ST
Practice Address - Street 2:
Practice Address - City:BERKELEY
Practice Address - State:CA
Practice Address - Zip Code:94703-1117
Practice Address - Country:US
Practice Address - Phone:411-960-2723
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-11-03
Last Update Date:2011-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOT 12019174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist