MEDICARE: KELLY CHRISTOPHERSON

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	20335	CA

General Provider Information

NPI Number	:	1528105830
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KELLY CHRISTOPHERSON

Provider Business Mailing Address
First Line	:	5404 LAUREL HILLS DR
Second Line	:
City	:	SACRAMENTO
State	:	CA
Zip	:	95841-3106
Country	:	US
Telephone Number	:	916-608-4008
Fax Number	:	916-609-6360

Provider Business Practice Location Address
First Line	:	5404 LAUREL HILLS DR
Second Line	:
City	:	SACRAMENTO
State	:	CA
Zip	:	95841-3106
Country	:	US
Telephone Number	:	916-608-4008
Fax Number	:	916-609-6360

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/30/2007
Last Update Date	:	07/08/2007

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