Provider Demographics
NPI:1609283464
Name:SAYSAMPHAN, CHRISTINA NICKIE (LMT)
Entity Type:Individual
Prefix:
First Name:CHRISTINA
Middle Name:NICKIE
Last Name:SAYSAMPHAN
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7 MARCIA CT
Mailing Address - Street 2:
Mailing Address - City:SOUTH ELGIN
Mailing Address - State:IL
Mailing Address - Zip Code:60177-3059
Mailing Address - Country:US
Mailing Address - Phone:847-274-3214
Mailing Address - Fax:
Practice Address - Street 1:1425 N MCLEAN BLVD STE 700
Practice Address - Street 2:
Practice Address - City:ELGIN
Practice Address - State:IL
Practice Address - Zip Code:60123-5724
Practice Address - Country:US
Practice Address - Phone:847-695-0464
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-14
Last Update Date:2014-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL227014189225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist