Provider Demographics
NPI:1952811002
Name:LAISE, CHRISTOPHER MICHAEL
Entity Type:Individual
Prefix:
First Name:CHRISTOPHER
Middle Name:MICHAEL
Last Name:LAISE
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 1:2019 14TH AVE NW APT F254
Mailing Address - Street 2:
Mailing Address - City:GIG HARBOR
Mailing Address - State:WA
Mailing Address - Zip Code:98335-1665
Mailing Address - Country:US
Mailing Address - Phone:253-302-1196
Mailing Address - Fax:
Practice Address - Street 1:2430 N 13TH ST
Practice Address - Street 2:
Practice Address - City:SHELTON
Practice Address - State:WA
Practice Address - Zip Code:98584-1213
Practice Address - Country:US
Practice Address - Phone:360-426-1651
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-10-03
Last Update Date:2017-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA60790708224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant