Provider Demographics
NPI:1104327212
Name:DETTBARN, CHRISTINA L (MS, CCC-SLP)
Entity type:Individual
Prefix:MRS
First Name:CHRISTINA
Middle Name:L
Last Name:DETTBARN
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:MRS
Other - First Name:TINA
Other - Middle Name:TAYLOR
Other - Last Name:DETTBARN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MS,CCC-SLP
Mailing Address - Street 1:912 S BIRDNECK RD
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23451-4802
Mailing Address - Country:US
Mailing Address - Phone:757-648-3720
Mailing Address - Fax:
Practice Address - Street 1:912 S BIRDNECK RD
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23451-4802
Practice Address - Country:US
Practice Address - Phone:757-648-3720
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-23
Last Update Date:2018-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2202007827235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist