Provider Demographics
NPI:1801364229
Name:BECK, CHRISTINA ELISE
Entity Type:Individual
Prefix:
First Name:CHRISTINA
Middle Name:ELISE
Last Name:BECK
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 1:660 S CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:BARTOW
Mailing Address - State:FL
Mailing Address - Zip Code:33830-4627
Mailing Address - Country:US
Mailing Address - Phone:863-430-7539
Mailing Address - Fax:
Practice Address - Street 1:4404 S FLORIDA AVE
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33813-2169
Practice Address - Country:US
Practice Address - Phone:863-709-8110
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-03
Last Update Date:2018-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLIMH17461101YM0800X
FLIMH18461101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLIMH17461OtherREGISTERED LMHC INTERN