Provider Demographics
NPI:1558914473
Name:BAIN, CRISTINA VALDIVIESO (PHD)
Entity Type:Individual
Prefix:DR
First Name:CRISTINA
Middle Name:VALDIVIESO
Last Name:BAIN
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:CRISTINA
Other - Middle Name:MAYLEN
Other - Last Name:VALDIVIESO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:902 WILSON RD
Mailing Address - Street 2:
Mailing Address - City:SMITHFIELD
Mailing Address - State:VA
Mailing Address - Zip Code:23430-1726
Mailing Address - Country:US
Mailing Address - Phone:757-635-9180
Mailing Address - Fax:
Practice Address - Street 1:100 EMANCIPATION DR
Practice Address - Street 2:
Practice Address - City:HAMPTON
Practice Address - State:VA
Practice Address - Zip Code:23667-0001
Practice Address - Country:US
Practice Address - Phone:757-722-9961
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-19
Last Update Date:2019-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0810006258103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical