Provider Demographics
NPI:1497829204
Name:VAVAK, CHRISTINE RAE (PHD)
Entity Type:Individual
Prefix:DR
First Name:CHRISTINE
Middle Name:RAE
Last Name:VAVAK
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:666 BLISS RD
Mailing Address - Street 2:SUITE 1
Mailing Address - City:LONGMEADOW
Mailing Address - State:MA
Mailing Address - Zip Code:01106-1562
Mailing Address - Country:US
Mailing Address - Phone:413-567-4515
Mailing Address - Fax:413-567-4515
Practice Address - Street 1:666 BLISS RD
Practice Address - Street 2:SUITE 1
Practice Address - City:LONGMEADOW
Practice Address - State:MA
Practice Address - Zip Code:01106-1562
Practice Address - Country:US
Practice Address - Phone:413-567-4515
Practice Address - Fax:413-567-4515
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA6667103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAW06188OtherBLUE CROSS BLUE SHIELD
MA1858645Medicaid
W50273Medicare ID - Type Unspecified