Provider Demographics
NPI:1447633573
Name:HORN, CHRISTINE KELLISH (BA, ITFS)
Entity type:Individual
Prefix:
First Name:CHRISTINE
Middle Name:KELLISH
Last Name:HORN
Suffix:
Gender:F
Credentials:BA, ITFS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:299 LOOKOUT DR
Mailing Address - Street 2:
Mailing Address - City:PISGAH FOREST
Mailing Address - State:NC
Mailing Address - Zip Code:28768-7749
Mailing Address - Country:US
Mailing Address - Phone:828-772-1078
Mailing Address - Fax:
Practice Address - Street 1:299 LOOKOUT DR
Practice Address - Street 2:
Practice Address - City:PISGAH FOREST
Practice Address - State:NC
Practice Address - Zip Code:28768-7749
Practice Address - Country:US
Practice Address - Phone:828-772-1078
Practice Address - Fax:828-639-8041
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-07
Last Update Date:2017-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
251S00000X, 222Q00000X, 251S00000X, 174400000X
NC252Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
No251S00000XAgenciesCommunity/Behavioral Health
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist
No252Y00000XAgenciesEarly Intervention Provider Agency
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC000000000Medicaid
NC0000000000OtherDHHS INFANT TODDLER PROGRAM