Healthcare Provider Details

I. General information

NPI: 1194139170
Provider Name (Legal Business Name): CHRISTINE HEAD LSWAIC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/17/2014
Last Update Date: 05/10/2026
Certification Date: 05/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

64 MARTIN FARM RD
JASPER GA
30143-5710
US

IV. Provider business mailing address

64 MARTIN FARM RD
JASPER GA
30143-5710
US

V. Phone/Fax

Practice location:
  • Phone: 706-383-3826
  • Fax:
Mailing address:
  • Phone: 253-283-1213
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberCSW009056
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberSC60838766
License Number StateWA
# 3
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number0904020424
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: