Provider Demographics
NPI:1154578219
Name:CHRISTENSON, KIMBERLY MARIE (PTA)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:MARIE
Last Name:CHRISTENSON
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1231 KLINGER RD
Mailing Address - Street 2:
Mailing Address - City:CONVOY
Mailing Address - State:OH
Mailing Address - Zip Code:45832-9226
Mailing Address - Country:US
Mailing Address - Phone:317-508-0738
Mailing Address - Fax:
Practice Address - Street 1:1231 KLINGER RD
Practice Address - Street 2:
Practice Address - City:CONVOY
Practice Address - State:OH
Practice Address - Zip Code:45832-9226
Practice Address - Country:US
Practice Address - Phone:317-508-0738
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-20
Last Update Date:2008-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN06003236A225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant