Provider Demographics
NPI:1194057091
Name:RAE, KRISTINE MAIA (PT)
Entity type:Individual
Prefix:
First Name:KRISTINE
Middle Name:MAIA
Last Name:RAE
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:KRISTINE
Other - Middle Name:MAIA
Other - Last Name:BATTEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1905 PINE ST
Mailing Address - Street 2:
Mailing Address - City:SANDPOINT
Mailing Address - State:ID
Mailing Address - Zip Code:83864-8311
Mailing Address - Country:US
Mailing Address - Phone:208-290-2504
Mailing Address - Fax:208-255-2423
Practice Address - Street 1:1905 PINE ST
Practice Address - Street 2:
Practice Address - City:SANDPOINT
Practice Address - State:ID
Practice Address - Zip Code:83864-8311
Practice Address - Country:US
Practice Address - Phone:208-263-7998
Practice Address - Fax:208-255-2423
Is Sole Proprietor?:No
Enumeration Date:2010-02-03
Last Update Date:2019-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPT-5344225100000X
WAPT00008363225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDPT-5344OtherPT LICENSE