Provider Demographics
NPI:1093489601
Name:ROUSSEAU, KRYSIA KRISTINE (DPT)
Entity Type:Individual
Prefix:
First Name:KRYSIA
Middle Name:KRISTINE
Last Name:ROUSSEAU
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:704 N NEBULA CT
Mailing Address - Street 2:
Mailing Address - City:STAR
Mailing Address - State:ID
Mailing Address - Zip Code:83669-5554
Mailing Address - Country:US
Mailing Address - Phone:208-703-9824
Mailing Address - Fax:
Practice Address - Street 1:704 N NEBULA CT
Practice Address - Street 2:
Practice Address - City:STAR
Practice Address - State:ID
Practice Address - Zip Code:83669-5554
Practice Address - Country:US
Practice Address - Phone:208-703-9824
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-06
Last Update Date:2021-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID7161225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist