Provider Demographics
NPI:1699330027
Name:CHRISTIE, CLINT ROBERT (MA)
Entity type:Individual
Prefix:
First Name:CLINT
Middle Name:ROBERT
Last Name:CHRISTIE
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:333 3RD ST STE 6
Mailing Address - Street 2:
Mailing Address - City:LAGUNA BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92651-2376
Mailing Address - Country:US
Mailing Address - Phone:949-244-9488
Mailing Address - Fax:
Practice Address - Street 1:333 3RD ST STE 6
Practice Address - Street 2:
Practice Address - City:LAGUNA BEACH
Practice Address - State:CA
Practice Address - Zip Code:92651-2376
Practice Address - Country:US
Practice Address - Phone:949-244-9488
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-01
Last Update Date:2019-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA102855106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist