Provider Demographics
NPI:1528410206
Name:CARLLSON, CHRISTINE KAY
Entity Type:Individual
Prefix:
First Name:CHRISTINE
Middle Name:KAY
Last Name:CARLLSON
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 1:309 CARMEL VALLEY WAY
Mailing Address - Street 2:
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73025-2748
Mailing Address - Country:US
Mailing Address - Phone:405-476-1238
Mailing Address - Fax:
Practice Address - Street 1:309 CARMEL VALLEY WAY
Practice Address - Street 2:
Practice Address - City:EDMOND
Practice Address - State:OK
Practice Address - Zip Code:73025-2748
Practice Address - Country:US
Practice Address - Phone:405-476-1238
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-06
Last Update Date:2016-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker