Provider Demographics
NPI:1164741062
Name:NIDA, CHRISTINE ANN (MHR, LPC)
Entity Type:Individual
Prefix:MRS
First Name:CHRISTINE
Middle Name:ANN
Last Name:NIDA
Suffix:
Gender:F
Credentials:MHR, LPC
Other - Prefix:MRS
Other - First Name:CHRISTY
Other - Middle Name:
Other - Last Name:NIDA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MHR, LPC
Mailing Address - Street 1:39995 ROUND MTN LN
Mailing Address - Street 2:
Mailing Address - City:HOWE
Mailing Address - State:OK
Mailing Address - Zip Code:74940-7415
Mailing Address - Country:US
Mailing Address - Phone:918-658-5027
Mailing Address - Fax:
Practice Address - Street 1:320 DEWEY AVE
Practice Address - Street 2:
Practice Address - City:POTEAU
Practice Address - State:OK
Practice Address - Zip Code:74953-4212
Practice Address - Country:US
Practice Address - Phone:918-647-4196
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-18
Last Update Date:2010-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK3928101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100731330-AMedicaid