Provider Demographics
NPI:1396313896
Name:DACOSTA, KRISTEN
Entity type:Individual
Prefix:
First Name:KRISTEN
Middle Name:
Last Name:DACOSTA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:152 KINGS HWY
Mailing Address - Street 2:
Mailing Address - City:MIDDLETOWN
Mailing Address - State:NJ
Mailing Address - Zip Code:07748-2023
Mailing Address - Country:US
Mailing Address - Phone:173-269-3129
Mailing Address - Fax:
Practice Address - Street 1:54 N PARK AVE
Practice Address - Street 2:
Practice Address - City:SHREWSBURY
Practice Address - State:NJ
Practice Address - Zip Code:07702-4413
Practice Address - Country:US
Practice Address - Phone:917-406-0478
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-12
Last Update Date:2021-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJPT40QA007732002251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics