Provider Demographics
NPI:1891981775
Name:HERGREN, CHRISTINE JO (MA, LLP, CAAC)
Entity Type:Individual
Prefix:MS
First Name:CHRISTINE
Middle Name:JO
Last Name:HERGREN
Suffix:
Gender:F
Credentials:MA, LLP, CAAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15306 HELEN ST
Mailing Address - Street 2:
Mailing Address - City:SOUTHGATE
Mailing Address - State:MI
Mailing Address - Zip Code:48195-2068
Mailing Address - Country:US
Mailing Address - Phone:313-475-8888
Mailing Address - Fax:
Practice Address - Street 1:15306 HELEN ST
Practice Address - Street 2:
Practice Address - City:SOUTHGATE
Practice Address - State:MI
Practice Address - Zip Code:48195-2068
Practice Address - Country:US
Practice Address - Phone:313-475-8888
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-09-24
Last Update Date:2010-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301013667103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist