Provider Demographics
NPI:1790298354
Name:CHRISTIE, SHANAIRA
Entity Type:Individual
Prefix:MRS
First Name:SHANAIRA
Middle Name:
Last Name:CHRISTIE
Suffix:
Gender:F
Credentials:
Other - Prefix:MISS
Other - First Name:SHANAIRA
Other - Middle Name:
Other - Last Name:FOGLE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:205 WAKELEE AVE
Mailing Address - Street 2:
Mailing Address - City:ANSONIA
Mailing Address - State:CT
Mailing Address - Zip Code:06401-1234
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:205 WAKELEE AVENUE
Practice Address - Street 2:
Practice Address - City:ANSONIA
Practice Address - State:CT
Practice Address - Zip Code:06401
Practice Address - Country:US
Practice Address - Phone:203-735-7481
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-11-06
Last Update Date:2017-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist