Provider Demographics
NPI:1104998160
Name:BROWN, CHRISTINE BOMEISL
Entity type:Individual
Prefix:
First Name:CHRISTINE
Middle Name:BOMEISL
Last Name:BROWN
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 1:1922 SADLER DR SE
Mailing Address - Street 2:
Mailing Address - City:SMYRNA
Mailing Address - State:GA
Mailing Address - Zip Code:30080-5815
Mailing Address - Country:US
Mailing Address - Phone:770-426-5708
Mailing Address - Fax:770-434-3999
Practice Address - Street 1:116 FORREST AVE
Practice Address - Street 2:
Practice Address - City:CARTERSVILLE
Practice Address - State:GA
Practice Address - Zip Code:30120-3640
Practice Address - Country:US
Practice Address - Phone:770-382-3206
Practice Address - Fax:770-382-3276
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-14
Last Update Date:2011-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOT002476225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA52825966 003OtherBLUE CROSS BLUE SHIELD
GA52825966 002OtherBLUE CROSS BLUE SHIELD
GA312665OtherWELLCARE
GA52825966 001OtherBLUE CROSS BLUE SHIELD
GA000835436AOtherPEACH STATE HEALTH PLAN
GA000835436AMedicaid
GA10035959OtherAMERIGROUP