Provider Demographics
NPI:1073069423
Name:PREMUS, KRISTEN VICTORIA (DROT, OTR/L)
Entity Type:Individual
Prefix:
First Name:KRISTEN
Middle Name:VICTORIA
Last Name:PREMUS
Suffix:
Gender:F
Credentials:DROT, OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 LINDIS FARNE AVE
Mailing Address - Street 2:#1103
Mailing Address - City:HADDON TOWNSHIP
Mailing Address - State:NJ
Mailing Address - Zip Code:08108-2700
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:475 SPRING LN
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19128-3918
Practice Address - Country:US
Practice Address - Phone:215-482-5353
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-26
Last Update Date:2016-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOC01225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist