Provider Demographics
NPI:1558450734
Name:MCILWAIN, CHRISTINE D (MFT)
Entity Type:Individual
Prefix:MS
First Name:CHRISTINE
Middle Name:D
Last Name:MCILWAIN
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 10671
Mailing Address - Street 2:
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92658-5004
Mailing Address - Country:US
Mailing Address - Phone:714-834-7926
Mailing Address - Fax:714-834-8235
Practice Address - Street 1:1725 W 17TH ST
Practice Address - Street 2:
Practice Address - City:SANTA ANA
Practice Address - State:CA
Practice Address - Zip Code:92706-2316
Practice Address - Country:US
Practice Address - Phone:714-834-7926
Practice Address - Fax:714-834-8235
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAM13424106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist