Provider Demographics
NPI:1417728205
Name:BENNETT-SHULTZ, CHRISTENE ALVA
Entity Type:Individual
Prefix:
First Name:CHRISTENE
Middle Name:ALVA
Last Name:BENNETT-SHULTZ
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 1:51 E LAKESHORE DR
Mailing Address - Street 2:
Mailing Address - City:ALLYN
Mailing Address - State:WA
Mailing Address - Zip Code:98524-8792
Mailing Address - Country:US
Mailing Address - Phone:253-441-7222
Mailing Address - Fax:
Practice Address - Street 1:1520 NE RIDDELL RD STE 110
Practice Address - Street 2:
Practice Address - City:BREMERTON
Practice Address - State:WA
Practice Address - Zip Code:98310-3005
Practice Address - Country:US
Practice Address - Phone:360-228-7246
Practice Address - Fax:360-228-7247
Is Sole Proprietor?:No
Enumeration Date:2024-01-11
Last Update Date:2024-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA61510414101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)