Provider Demographics
NPI:1740618982
Name:DETROIS, CHRISTINE ALEXANDRA
Entity Type:Individual
Prefix:MRS
First Name:CHRISTINE
Middle Name:ALEXANDRA
Last Name:DETROIS
Suffix:
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:CHRISTINE
Other - Middle Name:ALEXANDRA
Other - Last Name:PRIORE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:821 SAGINAW ST S
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97302-4121
Mailing Address - Country:US
Mailing Address - Phone:503-589-4046
Mailing Address - Fax:503-480-0484
Practice Address - Street 1:821 SAGINAW ST S
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97302-4121
Practice Address - Country:US
Practice Address - Phone:503-589-4046
Practice Address - Fax:503-480-0484
Is Sole Proprietor?:No
Enumeration Date:2013-10-25
Last Update Date:2024-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL222Q00000X
OR23-QMHA-II-000119171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR1740618982Medicaid