Healthcare Provider Details

I. General information

NPI: 1396560736
Provider Name (Legal Business Name): CHRISTINE A CALVIN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/20/2024
Last Update Date: 11/21/2024
Certification Date: 11/21/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1111 N RUSSELL RD
BLOOMINGTON IN
47408-9482
US

IV. Provider business mailing address

6468 E COX DR
BLOOMINGTON IN
47408-9517
US

V. Phone/Fax

Practice location:
  • Phone: 812-330-7753
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number1061819
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: