Provider Demographics
NPI:1457651473
Name:ETCHISON, CHRISTINA G (PHD, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:CHRISTINA
Middle Name:G
Last Name:ETCHISON
Suffix:
Gender:F
Credentials:PHD, CCC-SLP
Other - Prefix:
Other - First Name:CHRISTINA
Other - Middle Name:G
Other - Last Name:GENTRY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:54 SPRING RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:DEBARY
Mailing Address - State:FL
Mailing Address - Zip Code:32713-3727
Mailing Address - Country:US
Mailing Address - Phone:074-177-0204
Mailing Address - Fax:
Practice Address - Street 1:51 SPRING RIDGE DR
Practice Address - Street 2:
Practice Address - City:DEBARY
Practice Address - State:FL
Practice Address - Zip Code:32713-3725
Practice Address - Country:US
Practice Address - Phone:407-417-7020
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-10-25
Last Update Date:2023-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA 11608235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL002843300Medicaid