Provider Demographics
NPI:1063632115
Name:KISSENBERTH, KAREN P (PT)
Entity Type:Individual
Prefix:
First Name:KAREN
Middle Name:P
Last Name:KISSENBERTH
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:KAREN
Other - Middle Name:
Other - Last Name:PRICE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:103 N MAIN ST
Mailing Address - Street 2:STE 300
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29601-2796
Mailing Address - Country:US
Mailing Address - Phone:864-528-5700
Mailing Address - Fax:864-528-5701
Practice Address - Street 1:1020 GROVE ROAD
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29605
Practice Address - Country:US
Practice Address - Phone:864-455-2319
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-30
Last Update Date:2012-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1521225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCTH0128Medicaid
SCTH0128Medicaid