Provider Demographics
NPI:1407280498
Name:MONDRAGON, CHRISTINE
Entity Type:Individual
Prefix:MS
First Name:CHRISTINE
Middle Name:
Last Name:MONDRAGON
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 1:19600 GILMORE ST
Mailing Address - Street 2:
Mailing Address - City:RESEDA
Mailing Address - State:CA
Mailing Address - Zip Code:91335-5720
Mailing Address - Country:US
Mailing Address - Phone:818-921-2001
Mailing Address - Fax:
Practice Address - Street 1:14624 SHERMAN WAY STE 408
Practice Address - Street 2:
Practice Address - City:VAN NUYS
Practice Address - State:CA
Practice Address - Zip Code:91405-2289
Practice Address - Country:US
Practice Address - Phone:818-778-5406
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-08-26
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225400000X
CA694771041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner