Provider Demographics
NPI:1861854481
Name:CHRISTIAN, MICHAEL
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:
Last Name:CHRISTIAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4618 E STATE BLVD STE 300
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46815-6966
Mailing Address - Country:US
Mailing Address - Phone:260-373-0213
Mailing Address - Fax:260-373-0218
Practice Address - Street 1:4618 E STATE BLVD STE 300
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46815-6966
Practice Address - Country:US
Practice Address - Phone:603-730-2132
Practice Address - Fax:260-373-0218
Is Sole Proprietor?:No
Enumeration Date:2016-03-23
Last Update Date:2019-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN39003509A101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health