Provider Demographics
NPI:1942478839
Name:CHRISTOPHERSEN, LYN M (LISAC)
Entity Type:Individual
Prefix:
First Name:LYN
Middle Name:M
Last Name:CHRISTOPHERSEN
Suffix:
Gender:F
Credentials:LISAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:483 W SEED FARM RD
Mailing Address - Street 2:GILA RIVER HU HU KAM MEMORIAL MEDICAL CENTER RHBA
Mailing Address - City:SACATON
Mailing Address - State:AZ
Mailing Address - Zip Code:85247
Mailing Address - Country:US
Mailing Address - Phone:602-528-7151
Mailing Address - Fax:602-528-1374
Practice Address - Street 1:483 W SEED FARM RD
Practice Address - Street 2:GILA RIVER HU HU KAM MEMORIAL MEDICAL CENTER RHBA
Practice Address - City:SACATON
Practice Address - State:AZ
Practice Address - Zip Code:85247
Practice Address - Country:US
Practice Address - Phone:602-528-7151
Practice Address - Fax:602-528-1374
Is Sole Proprietor?:Yes
Enumeration Date:2008-02-14
Last Update Date:2008-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLISAC 0751101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ346214Medicaid