Healthcare Provider Details

I. General information

NPI: 1316742927
Provider Name (Legal Business Name): CHRISTINE CAROL FRAZIER LPC-IT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: MS. CHRISTINE CAROL DAVIDSON

II. Dates (important events)

Enumeration Date: 02/17/2025
Last Update Date: 02/17/2025
Certification Date: 02/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1807 N CENTER ST
BEAVER DAM WI
53916-1001
US

IV. Provider business mailing address

204 W BROWN ST APT 201
WAUPUN WI
53963-1973
US

V. Phone/Fax

Practice location:
  • Phone: 920-887-8751
  • Fax:
Mailing address:
  • Phone: 703-582-9406
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number8252-226
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code103TF0200X
TaxonomyForensic Psychologist
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: