Provider Demographics
NPI:1275950271
Name:BONGEN, CHRISTINA
Entity Type:Individual
Prefix:
First Name:CHRISTINA
Middle Name:
Last Name:BONGEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7420 SW 3RD AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97219-2801
Mailing Address - Country:US
Mailing Address - Phone:503-380-3906
Mailing Address - Fax:
Practice Address - Street 1:7420 SW 3RD AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97219-2801
Practice Address - Country:US
Practice Address - Phone:503-380-3906
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-03-27
Last Update Date:2014-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR1053031225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist