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General NPI Number Information
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NPI Number | 1144948175
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Entity Type | Individual
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Provider Name | CHRISTIAN WITHERELL PMHNP-BC
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Gender | Male
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Dates
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Enumeration Date | 08/16/2022
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Last Update Date | 04/15/2025
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Provider Practice Location Address
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Address Line | 19995 SOUNDVIEW AVE
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City | SOUTHOLD
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State | NY
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Zip | 11971-2820
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Country | US
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Telephone | 631-335-5541
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Fax | 631-939-2006
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Provider Business Mailing Address
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Address Line | 19995 SOUNDVIEW AVE
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City | SOUTHOLD
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State | NY
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Zip | 11971-2820
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LP0808X
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Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
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License Number | 404304
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License Number State | NY
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