Healthcare Provider Details

I. General information

NPI: 1194431213
Provider Name (Legal Business Name): CHRISTINE AMANDA MOKRY LCDC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/24/2023
Last Update Date: 01/24/2023
Certification Date: 01/24/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1165 AIRPORT BLVD
AUSTIN TX
78702-3152
US

IV. Provider business mailing address

1430 COLLIER ST
AUSTIN TX
78704-2911
US

V. Phone/Fax

Practice location:
  • Phone: 512-968-3395
  • Fax:
Mailing address:
  • Phone: 512-472-4357
  • Fax: 512-703-1394

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number16387
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: