Provider Demographics
NPI:1497533418
Name:CHRISTIE, CORY
Entity type:Individual
Prefix:
First Name:CORY
Middle Name:
Last Name:CHRISTIE
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 1:3744 MAHONING AVE NW
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:OH
Mailing Address - Zip Code:44483-1920
Mailing Address - Country:US
Mailing Address - Phone:234-283-3483
Mailing Address - Fax:
Practice Address - Street 1:1716 NORTH RD SE
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:OH
Practice Address - Zip Code:44484-2907
Practice Address - Country:US
Practice Address - Phone:330-539-3200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-20
Last Update Date:2024-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHAPS.004460175T00000X
101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No175T00000XOther Service ProvidersPeer SpecialistGroup - Single Specialty