Provider Demographics
NPI:1295318947
Name:SEAGRAVES, CHRISTINA MICHELLE
Entity type:Individual
Prefix:
First Name:CHRISTINA
Middle Name:MICHELLE
Last Name:SEAGRAVES
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 1:711 S 25TH ST STE 7
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98405-4306
Mailing Address - Country:US
Mailing Address - Phone:253-536-2881
Mailing Address - Fax:253-536-2956
Practice Address - Street 1:711 S 25TH ST STE 7
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98405-4306
Practice Address - Country:US
Practice Address - Phone:253-536-2881
Practice Address - Fax:253-536-2956
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-30
Last Update Date:2021-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA10001831Medicaid