Provider Demographics
NPI:1063064103
Name:JOHNSON, CHRISTINE LYNNE (CDC1)
Entity type:Individual
Prefix:
First Name:CHRISTINE
Middle Name:LYNNE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:CDC1
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3100 S CUSHMAN ST
Mailing Address - Street 2:
Mailing Address - City:FAIRBANKS
Mailing Address - State:AK
Mailing Address - Zip Code:99701-7516
Mailing Address - Country:US
Mailing Address - Phone:907-452-6251
Mailing Address - Fax:
Practice Address - Street 1:424 KETCHIKAN AVE
Practice Address - Street 2:
Practice Address - City:FAIRBANKS
Practice Address - State:AK
Practice Address - Zip Code:99701-3737
Practice Address - Country:US
Practice Address - Phone:907-374-1822
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-09
Last Update Date:2019-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK4026101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)