Provider Demographics
NPI:1790350221
Name:O'LEARY, CHRISTINE
Entity Type:Individual
Prefix:DR
First Name:CHRISTINE
Middle Name:
Last Name:O'LEARY
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 1:5902 HOMESTEAD RD
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46814-4202
Mailing Address - Country:US
Mailing Address - Phone:260-434-0207
Mailing Address - Fax:
Practice Address - Street 1:5902 HOMESTEAD RD
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46814-4202
Practice Address - Country:US
Practice Address - Phone:260-434-0207
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-26
Last Update Date:2021-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN24007106A405300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes405300000XOther Service ProvidersPrevention Professional