Provider Demographics
NPI:1700099595
Name:VAN DOREN, CHRISTOPHER RAY (LCPC)
Entity Type:Individual
Prefix:
First Name:CHRISTOPHER
Middle Name:RAY
Last Name:VAN DOREN
Suffix:
Gender:M
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:95 PARKER ST
Mailing Address - Street 2:C/O HOSA
Mailing Address - City:NEWBURYPORT
Mailing Address - State:MA
Mailing Address - Zip Code:01950-4033
Mailing Address - Country:US
Mailing Address - Phone:978-225-2250
Mailing Address - Fax:978-225-2251
Practice Address - Street 1:11 BRICK HILL RD
Practice Address - Street 2:
Practice Address - City:WINDHAM
Practice Address - State:ME
Practice Address - Zip Code:04062-3359
Practice Address - Country:US
Practice Address - Phone:207-831-9480
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-08
Last Update Date:2010-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MECC3069101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME431538599Medicaid