Provider Demographics
NPI:1972036853
Name:MICK, CHRISITNE R (0131000159)
Entity Type:Individual
Prefix:
First Name:CHRISITNE
Middle Name:R
Last Name:MICK
Suffix:
Gender:F
Credentials:0131000159
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3610 KIEFER RD
Mailing Address - Street 2:
Mailing Address - City:CHESTER
Mailing Address - State:VA
Mailing Address - Zip Code:23831-1813
Mailing Address - Country:US
Mailing Address - Phone:804-748-4276
Mailing Address - Fax:
Practice Address - Street 1:8254 ATLEE RD
Practice Address - Street 2:
Practice Address - City:MECHANICSVILLE
Practice Address - State:VA
Practice Address - Zip Code:23116-1844
Practice Address - Country:US
Practice Address - Phone:804-342-4353
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-06
Last Update Date:2017-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0131000159261QR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0400XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation