Provider Demographics
NPI:1285716191
Name:TEBO, KRISTINA M (PHYSICAL THERAPIST)
Entity type:Individual
Prefix:MRS
First Name:KRISTINA
Middle Name:M
Last Name:TEBO
Suffix:
Gender:F
Credentials:PHYSICAL THERAPIST
Other - Prefix:
Other - First Name:KRISTINA
Other - Middle Name:MARIE
Other - Last Name:BERGSTROM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHYSICAL THERAPIST
Mailing Address - Street 1:1281 MARINETTE AVE
Mailing Address - Street 2:
Mailing Address - City:MARINETTE
Mailing Address - State:WI
Mailing Address - Zip Code:54143-2018
Mailing Address - Country:US
Mailing Address - Phone:715-735-5500
Mailing Address - Fax:715-735-5502
Practice Address - Street 1:1281 MARINETTE AVE
Practice Address - Street 2:
Practice Address - City:MARINETTE
Practice Address - State:WI
Practice Address - Zip Code:54143-2018
Practice Address - Country:US
Practice Address - Phone:715-735-5500
Practice Address - Fax:715-735-5502
Is Sole Proprietor?:No
Enumeration Date:2006-10-19
Last Update Date:2014-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1063124225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI36115900Medicaid
WI36115900Medicaid