Provider Demographics
NPI:1538518964
Name:ANDERSON, CHRISTINE GRACE
Entity Type:Individual
Prefix:
First Name:CHRISTINE
Middle Name:GRACE
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:
Other - Prefix:MISS
Other - First Name:CHRISTINE
Other - Middle Name:GRACE
Other - Last Name:ANDERSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:625 SE MAYLOR ST
Mailing Address - Street 2:
Mailing Address - City:OAK HARBOR
Mailing Address - State:WA
Mailing Address - Zip Code:98277-5413
Mailing Address - Country:US
Mailing Address - Phone:805-206-6465
Mailing Address - Fax:
Practice Address - Street 1:231 SE BARRINGTON DR STE 203
Practice Address - Street 2:
Practice Address - City:OAK HARBOR
Practice Address - State:WA
Practice Address - Zip Code:98277-3200
Practice Address - Country:US
Practice Address - Phone:360-240-0022
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-07
Last Update Date:2016-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA557863944OtherMEDICARE