Provider Demographics
NPI:1205335973
Name:SAMPLE, CHRISTOPHER (PSYD)
Entity type:Individual
Prefix:
First Name:CHRISTOPHER
Middle Name:
Last Name:SAMPLE
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4000 MACARTHUR BLVD
Mailing Address - Street 2:EAST TOWER, SUITE 600
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92649-2347
Mailing Address - Country:US
Mailing Address - Phone:703-244-4815
Mailing Address - Fax:949-209-4544
Practice Address - Street 1:4000 MACARTHUR BLVD STE 600
Practice Address - Street 2:
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92660-2517
Practice Address - Country:US
Practice Address - Phone:949-449-1335
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-07
Last Update Date:2018-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY29870103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical