Provider Demographics
NPI:1104104728
Name:COLVETT, CHRISTINE
Entity type:Individual
Prefix:
First Name:CHRISTINE
Middle Name:
Last Name:COLVETT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9801 67TH AVE
Mailing Address - Street 2:APT 3O
Mailing Address - City:REGO PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11374-9997
Mailing Address - Country:US
Mailing Address - Phone:914-204-1767
Mailing Address - Fax:
Practice Address - Street 1:9801 67TH AVE
Practice Address - Street 2:APT 3O
Practice Address - City:REGO PARK
Practice Address - State:NY
Practice Address - Zip Code:11374-4967
Practice Address - Country:US
Practice Address - Phone:914-204-1767
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-31
Last Update Date:2012-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103K00000X
NY500921111174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst