Provider Demographics
NPI:1285839159
Name:BAK, CHRISTINA MARIE (MS, TLLP)
Entity Type:Individual
Prefix:MRS
First Name:CHRISTINA
Middle Name:MARIE
Last Name:BAK
Suffix:
Gender:F
Credentials:MS, TLLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15763 20 MILE RD
Mailing Address - Street 2:
Mailing Address - City:MARSHALL
Mailing Address - State:MI
Mailing Address - Zip Code:49068-9455
Mailing Address - Country:US
Mailing Address - Phone:734-945-5133
Mailing Address - Fax:
Practice Address - Street 1:1308 S MAIN ST
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:MI
Practice Address - Zip Code:48170-2253
Practice Address - Country:US
Practice Address - Phone:734-451-3440
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301013458103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist