Provider Demographics
NPI:1134238264
Name:BURCHETT, CHRISTINA M (PHD)
Entity type:Individual
Prefix:DR
First Name:CHRISTINA
Middle Name:M
Last Name:BURCHETT
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:211 LANDMARK DR
Mailing Address - Street 2:SUITE B4E
Mailing Address - City:NORMAL
Mailing Address - State:IL
Mailing Address - Zip Code:61761-2160
Mailing Address - Country:US
Mailing Address - Phone:309-830-8099
Mailing Address - Fax:
Practice Address - Street 1:211 LANDMARK DR
Practice Address - Street 2:SUITE B4E
Practice Address - City:NORMAL
Practice Address - State:IL
Practice Address - Zip Code:61761-2160
Practice Address - Country:US
Practice Address - Phone:309-830-8099
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-30
Last Update Date:2007-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071006988103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL214856Medicare PIN