Provider Demographics
NPI:1922231208
Name:HARRISON, CHRISTINE G (OT)
Entity Type:Individual
Prefix:
First Name:CHRISTINE
Middle Name:G
Last Name:HARRISON
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:CHRISTINE
Other - Middle Name:G
Other - Last Name:DOMMER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OT
Mailing Address - Street 1:PO BOX 40767
Mailing Address - Street 2:CREDENTIALING DEPARTMENT
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32203-0767
Mailing Address - Country:US
Mailing Address - Phone:904-376-3707
Mailing Address - Fax:904-391-5807
Practice Address - Street 1:5393 ROOSEVELT BLVD STE 17
Practice Address - Street 2:CREDENTIALING DEPARTMENT
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32210-8424
Practice Address - Country:US
Practice Address - Phone:904-389-8570
Practice Address - Fax:904-389-8599
Is Sole Proprietor?:No
Enumeration Date:2009-09-02
Last Update Date:2015-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOT13706225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLCK056ZMedicare PIN