Provider Demographics
NPI:1568290732
Name:THEODORE, CHRISTELLE
Entity type:Individual
Prefix:
First Name:CHRISTELLE
Middle Name:
Last Name:THEODORE
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 1:235 WELLESLEY ST STE 1
Mailing Address - Street 2:
Mailing Address - City:WESTON
Mailing Address - State:MA
Mailing Address - Zip Code:02493-1571
Mailing Address - Country:US
Mailing Address - Phone:908-494-2587
Mailing Address - Fax:
Practice Address - Street 1:1 HARRISON AVE
Practice Address - Street 2:
Practice Address - City:HARRISON
Practice Address - State:NJ
Practice Address - Zip Code:07029-1682
Practice Address - Country:US
Practice Address - Phone:908-494-2587
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-22
Last Update Date:2024-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NR22730500163WP0809X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0809XNursing Service ProvidersRegistered NursePsychiatric/Mental Health, Adult