Provider Demographics
NPI:1629527460
Name:TA, CHRISTINE K (PHD)
Entity Type:Individual
Prefix:
First Name:CHRISTINE
Middle Name:K
Last Name:TA
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1301 PINE AVE
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90813-3124
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1301 PINE AVE
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90813
Practice Address - Country:US
Practice Address - Phone:562-595-1159
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-21
Last Update Date:2022-09-08
Deactivation Date:2018-08-20
Deactivation Code:
Reactivation Date:2018-08-29
Provider Licenses
StateLicense IDTaxonomies
225C00000X
CAPSY33562103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No225C00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Counselor