Provider Demographics
NPI:1003150624
Name:BREESAWITZ, KRISTINA ALICE (PTA)
Entity Type:Individual
Prefix:MRS
First Name:KRISTINA
Middle Name:ALICE
Last Name:BREESAWITZ
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2218 FAIRFAX ST
Mailing Address - Street 2:
Mailing Address - City:PARKERSBURG
Mailing Address - State:WV
Mailing Address - Zip Code:26101-6940
Mailing Address - Country:US
Mailing Address - Phone:304-481-0607
Mailing Address - Fax:
Practice Address - Street 1:1716 GIHON RD
Practice Address - Street 2:
Practice Address - City:PARKERSBURG
Practice Address - State:WV
Practice Address - Zip Code:26101-9655
Practice Address - Country:US
Practice Address - Phone:304-485-5511
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-20
Last Update Date:2013-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV000621225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant