Provider Demographics
NPI:1194139170
Name:HEAD, CHRISTINE (LSWAIC)
Entity type:Individual
Prefix:
First Name:CHRISTINE
Middle Name:
Last Name:HEAD
Suffix:
Gender:F
Credentials:LSWAIC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:64 MARTIN FARM RD
Mailing Address - Street 2:
Mailing Address - City:JASPER
Mailing Address - State:GA
Mailing Address - Zip Code:30143-5710
Mailing Address - Country:US
Mailing Address - Phone:253-283-1213
Mailing Address - Fax:
Practice Address - Street 1:100 N HOWARD ST STE R
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99201-0508
Practice Address - Country:US
Practice Address - Phone:360-602-6611
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-06-17
Last Update Date:2021-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WASC608387661041C0700X
104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WASC60838766OtherLSWAIC