Provider Demographics
NPI:1306938741
Name:KIRISHIAN, MARTHA R (PT)
Entity type:Individual
Prefix:
First Name:MARTHA
Middle Name:R
Last Name:KIRISHIAN
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 1:12878 MYSTIC MINE RD
Mailing Address - Street 2:
Mailing Address - City:NEVADA CITY
Mailing Address - State:CA
Mailing Address - Zip Code:95959-9006
Mailing Address - Country:US
Mailing Address - Phone:530-274-2320
Mailing Address - Fax:530-274-1568
Practice Address - Street 1:300 SIERRA COLLEGE DR STE 165
Practice Address - Street 2:
Practice Address - City:GRASS VALLEY
Practice Address - State:CA
Practice Address - Zip Code:95945-5083
Practice Address - Country:US
Practice Address - Phone:530-274-2320
Practice Address - Fax:530-274-1568
Is Sole Proprietor?:No
Enumeration Date:2006-09-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT7894225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist