Provider Demographics
NPI:1194889915
Name:MATUSZ, KRISTEN RAE (PT)
Entity type:Individual
Prefix:
First Name:KRISTEN
Middle Name:RAE
Last Name:MATUSZ
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:KRISTEN
Other - Middle Name:RAE
Other - Last Name:PODEIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:6159 GEORGE ANN CT.
Mailing Address - Street 2:
Mailing Address - City:BELMONT
Mailing Address - State:MI
Mailing Address - Zip Code:49306
Mailing Address - Country:US
Mailing Address - Phone:616-250-0199
Mailing Address - Fax:
Practice Address - Street 1:6159 GEORGE ANN CT.
Practice Address - Street 2:
Practice Address - City:BELMONT
Practice Address - State:MI
Practice Address - Zip Code:49306
Practice Address - Country:US
Practice Address - Phone:616-250-0199
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-19
Last Update Date:2013-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT00010153225100000X
NM3341225100000X
MI5501013314225100000X
IL70015778225100000X
TX1170918225100000X
NCP12257225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist