Provider Demographics
NPI:1245353440
Name:JOHN L CHRISTENSEN PHD PC
Entity type:Organization
Organization Name:JOHN L CHRISTENSEN PHD PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:SECRETARY
Authorized Official - Prefix:
Authorized Official - First Name:NICHOLE
Authorized Official - Middle Name:
Authorized Official - Last Name:CHRISTENSEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-234-1707
Mailing Address - Street 1:13235 N MANNING LN
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83202-5184
Mailing Address - Country:US
Mailing Address - Phone:208-233-0150
Mailing Address - Fax:208-233-0159
Practice Address - Street 1:500 S 11TH AVE
Practice Address - Street 2:SUITE 302
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201
Practice Address - Country:US
Practice Address - Phone:208-233-0150
Practice Address - Fax:208-233-0159
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:JOHN L CHRISTENSEN PHD PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-04-10
Last Update Date:2009-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPSY202148251S00000X, 225C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225C00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation CounselorGroup - Single Specialty
No251S00000XAgenciesCommunity/Behavioral HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID807691400Medicaid