Provider Demographics
NPI:1992965172
Name:BISSETTE, KRISTEN M (OTRL)
Entity type:Individual
Prefix:MS
First Name:KRISTEN
Middle Name:M
Last Name:BISSETTE
Suffix:
Gender:F
Credentials:OTRL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12150 CAMP CHARLES ROAD
Mailing Address - Street 2:
Mailing Address - City:BAILEY
Mailing Address - State:NC
Mailing Address - Zip Code:27807
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1811 FOREST HILLS RD W
Practice Address - Street 2:
Practice Address - City:WILSON
Practice Address - State:NC
Practice Address - Zip Code:27893-3412
Practice Address - Country:US
Practice Address - Phone:252-243-7400
Practice Address - Fax:252-243-3291
Is Sole Proprietor?:No
Enumeration Date:2008-06-11
Last Update Date:2008-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC4986225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC0777YOtherBCBS
NC720777YMedicaid
NC720777YMedicaid