Provider Demographics
NPI:1235852468
Name:OWEN, CHRISTOPHER KYLE
Entity Type:Individual
Prefix:
First Name:CHRISTOPHER
Middle Name:KYLE
Last Name:OWEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3164 ANN ARBOR SALINE RD APT 204
Mailing Address - Street 2:
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48103-9858
Mailing Address - Country:US
Mailing Address - Phone:484-356-8535
Mailing Address - Fax:
Practice Address - Street 1:3005 BOARDWALK ST STE 201
Practice Address - Street 2:
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48108-5218
Practice Address - Country:US
Practice Address - Phone:734-222-9277
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-22
Last Update Date:2022-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6352000733103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI6352000733OtherDOCTORAL TEMPORARY EDUCATIONAL LIMITED LICENSE - PSYCHOLOGIST (TLLP)