Provider Demographics
NPI:1265007348
Name:MORTIMER, CHRISTA
Entity Type:Individual
Prefix:
First Name:CHRISTA
Middle Name:
Last Name:MORTIMER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:CHRISTA
Other - Middle Name:
Other - Last Name:MOORE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCPC
Mailing Address - Street 1:408 GOLDEN VALLEY DR
Mailing Address - Street 2:
Mailing Address - City:BOZEMAN
Mailing Address - State:MT
Mailing Address - Zip Code:59718-1922
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:333 HAGGERTY LN STE 9
Practice Address - Street 2:
Practice Address - City:BOZEMAN
Practice Address - State:MT
Practice Address - Zip Code:59715-1780
Practice Address - Country:US
Practice Address - Phone:406-633-0922
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-21
Last Update Date:2021-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTBBH-LCPC-LIC-48479101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor