Provider Demographics
NPI:1386127504
Name:PARK, CHRISTA (DPT)
Entity type:Individual
Prefix:
First Name:CHRISTA
Middle Name:
Last Name:PARK
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:70 ABIGAIL LN
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:WV
Mailing Address - Zip Code:25840-9203
Mailing Address - Country:US
Mailing Address - Phone:304-619-4501
Mailing Address - Fax:
Practice Address - Street 1:152 SADDLESHOP RD
Practice Address - Street 2:
Practice Address - City:HILLTOP
Practice Address - State:WV
Practice Address - Zip Code:25855
Practice Address - Country:US
Practice Address - Phone:304-469-2966
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-13
Last Update Date:2018-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV003882225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist