Provider Demographics
NPI:1225409220
Name:KOMOR, CHRISTIAN ROBERT (PSYD)
Entity Type:Individual
Prefix:DR
First Name:CHRISTIAN
Middle Name:ROBERT
Last Name:KOMOR
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:428 CHILDERS ST
Mailing Address - Street 2:PMB 24256
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32534-9630
Mailing Address - Country:US
Mailing Address - Phone:616-706-6951
Mailing Address - Fax:
Practice Address - Street 1:235 LOUIS ST NW
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-2600
Practice Address - Country:US
Practice Address - Phone:616-706-6951
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-15
Last Update Date:2016-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301005480103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIM032644OtherCHAMPUS
MIOD14598Medicaid