Provider Demographics
NPI:1083697346
Name:MATTHEWS, KRISTINA DIANE (MPT)
Entity type:Individual
Prefix:MRS
First Name:KRISTINA
Middle Name:DIANE
Last Name:MATTHEWS
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:MS
Other - First Name:KRISTINA
Other - Middle Name:DIANE
Other - Last Name:PORTER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MPT
Mailing Address - Street 1:5214 S EAST ST
Mailing Address - Street 2:BUILDING D SUITE 1
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46227-1917
Mailing Address - Country:US
Mailing Address - Phone:800-486-4449
Mailing Address - Fax:317-780-3745
Practice Address - Street 1:74 JOURNEY WAY
Practice Address - Street 2:
Practice Address - City:VALPARAISO
Practice Address - State:IN
Practice Address - Zip Code:46383-0078
Practice Address - Country:US
Practice Address - Phone:219-255-4378
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-21
Last Update Date:2024-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225100000X
KY004686225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist