Provider Demographics
NPI:1336644830
Name:CHRESTAY, CHRISTINE
Entity Type:Individual
Prefix:
First Name:CHRISTINE
Middle Name:
Last Name:CHRESTAY
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 1:278 BROADWAY AVE
Mailing Address - Street 2:
Mailing Address - City:YOUNGSTOWN
Mailing Address - State:OH
Mailing Address - Zip Code:44504-1752
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:278 BROADWAY AVE
Practice Address - Street 2:
Practice Address - City:YOUNGSTOWN
Practice Address - State:OH
Practice Address - Zip Code:44504-1752
Practice Address - Country:US
Practice Address - Phone:330-743-9275
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-27
Last Update Date:2019-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCDCA.16811101YA0400X
OHS0030435104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)