Provider Demographics
NPI:1386153955
Name:CHRISTIAN, THERESA (MED)
Entity type:Individual
Prefix:
First Name:THERESA
Middle Name:
Last Name:CHRISTIAN
Suffix:
Gender:F
Credentials:MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4924 MERLIN LN
Mailing Address - Street 2:
Mailing Address - City:GLEN ALLEN
Mailing Address - State:VA
Mailing Address - Zip Code:23060-4917
Mailing Address - Country:US
Mailing Address - Phone:804-290-8258
Mailing Address - Fax:
Practice Address - Street 1:4924 MERLIN LN
Practice Address - Street 2:
Practice Address - City:GLEN ALLEN
Practice Address - State:VA
Practice Address - Zip Code:23060-4917
Practice Address - Country:US
Practice Address - Phone:804-290-8258
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-26
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA252Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency