Provider Demographics
NPI:1124175898
Name:CHRISTENSEN, JOHN L (PHD)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:L
Last Name:CHRISTENSEN
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 4986
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83205-4986
Mailing Address - Country:US
Mailing Address - Phone:208-233-0150
Mailing Address - Fax:208-233-0159
Practice Address - Street 1:500 S 11TH AVE
Practice Address - Street 2:SUITE 302
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201-4835
Practice Address - Country:US
Practice Address - Phone:208-233-0150
Practice Address - Fax:208-233-0159
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPSY202148103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1684782Medicare ID - Type Unspecified