Provider Demographics
NPI:1053567834
Name:LADD, CHRISTINA MARIE (LMHC)
Entity type:Individual
Prefix:
First Name:CHRISTINA
Middle Name:MARIE
Last Name:LADD
Suffix:
Gender:F
Credentials:LMHC
Other - Prefix:
Other - First Name:CHRISTINA
Other - Middle Name:MARIE
Other - Last Name:CAVANAUGH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PCMHT
Mailing Address - Street 1:9870 NW UNION RD
Mailing Address - Street 2:
Mailing Address - City:MOORESVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46158-6123
Mailing Address - Country:US
Mailing Address - Phone:317-550-7553
Mailing Address - Fax:228-865-1700
Practice Address - Street 1:1600 BROAD AVE
Practice Address - Street 2:
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39501-3603
Practice Address - Country:US
Practice Address - Phone:228-863-1132
Practice Address - Fax:228-865-1700
Is Sole Proprietor?:No
Enumeration Date:2008-08-13
Last Update Date:2015-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS1906101YM0800X
IN39002270A101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00018213Medicaid