MEDICARE: MRS. CHRISTINA CHRISTENSEN LCPC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YA0400X	Addiction (Substance Use Disorder) Counselor	24201	IL
2	101YP2500X	Professional Counselor	180008820	IL

General Provider Information

NPI Number	:	1497178974
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. CHRISTINA CHRISTENSEN LCPC

Provider Business Mailing Address
First Line	:	1055 CROWN CT
Second Line	:
City	:	DIAMOND
State	:	IL
Zip	:	60416-3005
Country	:	US
Telephone Number	:	815-735-9108
Fax Number	:

Provider Business Practice Location Address
First Line	:	1055 CROWN CT
Second Line	:
City	:	DIAMOND
State	:	IL
Zip	:	60416-3005
Country	:	US
Telephone Number	:	815-735-9108
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/04/2014
Last Update Date	:	02/04/2014

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