Provider Demographics
NPI:1194349043
Name:HEIKKENEN-BLACK, CHRISTINE NELL (CRC, LPC, ACD)
Entity type:Individual
Prefix:
First Name:CHRISTINE
Middle Name:NELL
Last Name:HEIKKENEN-BLACK
Suffix:
Gender:F
Credentials:CRC, LPC, ACD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:SOUTHERN PEAKS REGIONAL TREATMENT CENTER
Mailing Address - Street 2:700 FOUR MILE PARKWAY
Mailing Address - City:CANON CITY
Mailing Address - State:CO
Mailing Address - Zip Code:81212-1101
Mailing Address - Country:US
Mailing Address - Phone:540-260-5559
Mailing Address - Fax:
Practice Address - Street 1:700 FOUR MILE PKWY
Practice Address - Street 2:
Practice Address - City:CANON CITY
Practice Address - State:CO
Practice Address - Zip Code:81212-9114
Practice Address - Country:US
Practice Address - Phone:540-260-5559
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-05
Last Update Date:2024-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COLPC101YP2500X101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Single Specialty