Provider Demographics
NPI:1770292153
Name:CHRISTOPHERSEN, KILEY MARIE
Entity type:Individual
Prefix:
First Name:KILEY
Middle Name:MARIE
Last Name:CHRISTOPHERSEN
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 1:890 CYPRESS AVE
Mailing Address - Street 2:
Mailing Address - City:REDDING
Mailing Address - State:CA
Mailing Address - Zip Code:96001-2715
Mailing Address - Country:US
Mailing Address - Phone:530-768-1880
Mailing Address - Fax:
Practice Address - Street 1:890 CYPRESS AVE
Practice Address - Street 2:
Practice Address - City:REDDING
Practice Address - State:CA
Practice Address - Zip Code:96001-2715
Practice Address - Country:US
Practice Address - Phone:530-232-0519
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-11-15
Last Update Date:2024-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA104100000X
175T00000X, 172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
No175T00000XOther Service ProvidersPeer Specialist