Provider Demographics
NPI:1114093572
Name:JOHNSON, KRISTINE C (PT)
Entity Type:Individual
Prefix:
First Name:KRISTINE
Middle Name:C
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:426 INDUSTRIAL AVE
Mailing Address - Street 2:SUITE 190
Mailing Address - City:WILLISTON
Mailing Address - State:VT
Mailing Address - Zip Code:05495-4448
Mailing Address - Country:US
Mailing Address - Phone:802-860-4360
Mailing Address - Fax:802-488-3160
Practice Address - Street 1:120 GRAHAM WAY STE 110
Practice Address - Street 2:
Practice Address - City:SHELBURNE
Practice Address - State:VT
Practice Address - Zip Code:05482-7217
Practice Address - Country:US
Practice Address - Phone:802-657-7990
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-28
Last Update Date:2020-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT0400002908225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
06528521OtherBLUE CROSS
VT1021737Medicaid
43V402OtherMBP