Provider Demographics
NPI:1164191276
Name:ROOT, CHRISTINE NICOLE
Entity Type:Individual
Prefix:
First Name:CHRISTINE
Middle Name:NICOLE
Last Name:ROOT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23119 COTTONWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:MORENO VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92553-9661
Mailing Address - Country:US
Mailing Address - Phone:951-413-5130
Mailing Address - Fax:
Practice Address - Street 1:23119 COTTONWOOD AVE STE 100
Practice Address - Street 2:
Practice Address - City:MORENO VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92553-9661
Practice Address - Country:US
Practice Address - Phone:951-413-5130
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-10
Last Update Date:2024-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
CAR1408741020101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No171M00000XOther Service ProvidersCase Manager/Care Coordinator