Provider Demographics
NPI:1770666703
Name:CHRISTIANSEN, LORI
Entity Type:Individual
Prefix:MISS
First Name:LORI
Middle Name:
Last Name:CHRISTIANSEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:595 W GRANADA BLVD
Mailing Address - Street 2:SUITE H
Mailing Address - City:ORMOND BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32174-5190
Mailing Address - Country:US
Mailing Address - Phone:386-677-3995
Mailing Address - Fax:386-673-0130
Practice Address - Street 1:595 W GRANADA BLVD
Practice Address - Street 2:SUITE H
Practice Address - City:ORMOND BEACH
Practice Address - State:FL
Practice Address - Zip Code:32174-5190
Practice Address - Country:US
Practice Address - Phone:386-677-3995
Practice Address - Fax:386-673-0130
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH7429101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health