Provider Demographics
NPI:1275078842
Name:VANN, CHRISTINA (1085109162)
Entity Type:Individual
Prefix:
First Name:CHRISTINA
Middle Name:
Last Name:VANN
Suffix:
Gender:F
Credentials:1085109162
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 S 7TH AVE
Mailing Address - Street 2:
Mailing Address - City:MOUNT VERNON
Mailing Address - State:NY
Mailing Address - Zip Code:10550-3008
Mailing Address - Country:US
Mailing Address - Phone:917-893-0088
Mailing Address - Fax:
Practice Address - Street 1:111 S 7TH AVE
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:NY
Practice Address - Zip Code:10550-3008
Practice Address - Country:US
Practice Address - Phone:917-893-0088
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-01-05
Last Update Date:2017-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1085109162103TS0200X, 174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
No103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool