Provider Demographics
NPI:1508005778
Name:ANDERSEN, CHRISTINE RUTH
Entity Type:Individual
Prefix:MRS
First Name:CHRISTINE
Middle Name:RUTH
Last Name:ANDERSEN
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 1:17 FARRAGUT AVE
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80909-5686
Mailing Address - Country:US
Mailing Address - Phone:719-636-2122
Mailing Address - Fax:719-636-1116
Practice Address - Street 1:17 FARRAGUT AVE
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80909-5686
Practice Address - Country:US
Practice Address - Phone:719-636-2122
Practice Address - Fax:719-636-1116
Is Sole Proprietor?:Yes
Enumeration Date:2009-02-11
Last Update Date:2009-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO322D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children