Provider Demographics
NPI:1003385808
Name:BLANK, KRISTIN (PT)
Entity Type:Individual
Prefix:
First Name:KRISTIN
Middle Name:
Last Name:BLANK
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:KRISTIN
Other - Middle Name:
Other - Last Name:DYE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:10716 LA TUNA CANYON RD
Mailing Address - Street 2:
Mailing Address - City:SUN VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:91352-2130
Mailing Address - Country:US
Mailing Address - Phone:818-588-0288
Mailing Address - Fax:818-252-6450
Practice Address - Street 1:10716 LA TUNA CANYON RD
Practice Address - Street 2:
Practice Address - City:SUN VALLEY
Practice Address - State:CA
Practice Address - Zip Code:91352-2130
Practice Address - Country:US
Practice Address - Phone:818-588-0288
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-21
Last Update Date:2020-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT296873225100000X
MSPTH6587225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist