Provider Demographics
NPI:1689193666
Name:OVERTON, CHRISTA DIANE
Entity type:Individual
Prefix:
First Name:CHRISTA
Middle Name:DIANE
Last Name:OVERTON
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 1:3722 ADAMS AVE
Mailing Address - Street 2:APT 8
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92116
Mailing Address - Country:US
Mailing Address - Phone:619-436-8645
Mailing Address - Fax:
Practice Address - Street 1:2219 ODESSA CT
Practice Address - Street 2:
Practice Address - City:LEMON GROVE
Practice Address - State:CA
Practice Address - Zip Code:91945
Practice Address - Country:US
Practice Address - Phone:619-461-4871
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-11
Last Update Date:2017-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)