Provider Demographics
NPI:1639155864
Name:CHRISTENSEN, EDWIN R (PHD)
Entity type:Individual
Prefix:
First Name:EDWIN
Middle Name:R
Last Name:CHRISTENSEN
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5104 DAISY LN
Mailing Address - Street 2:
Mailing Address - City:MURRAY
Mailing Address - State:UT
Mailing Address - Zip Code:84123-4519
Mailing Address - Country:US
Mailing Address - Phone:801-261-4724
Mailing Address - Fax:
Practice Address - Street 1:5104 DAISY LN
Practice Address - Street 2:
Practice Address - City:MURRAY
Practice Address - State:UT
Practice Address - Zip Code:84123-4519
Practice Address - Country:US
Practice Address - Phone:801-261-4724
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-12-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT107082-2501103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling