Provider Demographics
NPI:1184298200
Name:CHRISTOFFERSEN, MORIAH JO
Entity type:Individual
Prefix:
First Name:MORIAH
Middle Name:JO
Last Name:CHRISTOFFERSEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:917 SNAEDLE RD
Mailing Address - Street 2:
Mailing Address - City:WHITEHALL
Mailing Address - State:MI
Mailing Address - Zip Code:49461-9147
Mailing Address - Country:US
Mailing Address - Phone:231-349-1293
Mailing Address - Fax:
Practice Address - Street 1:585 FREMONT ST
Practice Address - Street 2:
Practice Address - City:NEWAYGO
Practice Address - State:MI
Practice Address - Zip Code:49337-9766
Practice Address - Country:US
Practice Address - Phone:231-652-1638
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-13
Last Update Date:2021-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI7151001753235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist