Provider Demographics
NPI:1508359050
Name:WHALEN, CHRISTINA THERESA
Entity Type:Individual
Prefix:
First Name:CHRISTINA
Middle Name:THERESA
Last Name:WHALEN
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 1:35 W RALEIGH AVE
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10310-2744
Mailing Address - Country:US
Mailing Address - Phone:917-621-6309
Mailing Address - Fax:
Practice Address - Street 1:3767 RICHMOND AVE
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10312-3827
Practice Address - Country:US
Practice Address - Phone:718-967-0359
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-10
Last Update Date:2018-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY027071-1174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty