Provider Demographics
NPI:1275849895
Name:PROVO, KRISTIN MARIE (PT, DPT)
Entity type:Individual
Prefix:
First Name:KRISTIN
Middle Name:MARIE
Last Name:PROVO
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:KRISTIN
Other - Middle Name:MARIE
Other - Last Name:BRUCE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT, DPT
Mailing Address - Street 1:KIDSTART
Mailing Address - Street 2:5871 GROVELAND STATION RD
Mailing Address - City:MOUNT MORRIS
Mailing Address - State:NY
Mailing Address - Zip Code:14510-9767
Mailing Address - Country:US
Mailing Address - Phone:585-658-4023
Mailing Address - Fax:585-658-4066
Practice Address - Street 1:KIDSTART
Practice Address - Street 2:5871 GROVELAND STATION RD
Practice Address - City:MOUNT MORRIS
Practice Address - State:NY
Practice Address - Zip Code:14510-9767
Practice Address - Country:US
Practice Address - Phone:585-658-4023
Practice Address - Fax:585-658-4066
Is Sole Proprietor?:No
Enumeration Date:2010-08-19
Last Update Date:2023-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY033003225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist