Provider Demographics
NPI:1467282749
Name:WILTBANK, CHRISTIAN
Entity type:Individual
Prefix:
First Name:CHRISTIAN
Middle Name:
Last Name:WILTBANK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1655 E SOUTHERN AVE APT 11
Mailing Address - Street 2:
Mailing Address - City:TEMPE
Mailing Address - State:AZ
Mailing Address - Zip Code:85282-5616
Mailing Address - Country:US
Mailing Address - Phone:480-296-6761
Mailing Address - Fax:
Practice Address - Street 1:1951 W CAMELBACK RD STE 450
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85015-3474
Practice Address - Country:US
Practice Address - Phone:602-601-2401
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-02
Last Update Date:2024-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ18152225A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225A00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMusic Therapist