Provider Demographics
NPI:1194795997
Name:KRISTOVICH, DEBORAH JEAN (PT)
Entity type:Individual
Prefix:
First Name:DEBORAH
Middle Name:JEAN
Last Name:KRISTOVICH
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2312 N 30TH ST
Mailing Address - Street 2:STE 101
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98403
Mailing Address - Country:US
Mailing Address - Phone:253-396-9001
Mailing Address - Fax:253-396-1231
Practice Address - Street 1:2312 N 30TH ST
Practice Address - Street 2:STE 101
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98403
Practice Address - Country:US
Practice Address - Phone:253-396-9001
Practice Address - Fax:253-396-1231
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-24
Last Update Date:2010-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0152660OtherLABOR AND INDUSTRIES
WA710935Medicaid
WA0152661OtherL AND I GROUP
WA710935Medicaid
S67777Medicare UPIN