Provider Demographics
NPI:1144246018
Name:CLEAVER, KRISTY LYNN (MPT)
Entity Type:Individual
Prefix:
First Name:KRISTY
Middle Name:LYNN
Last Name:CLEAVER
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:KRISTY
Other - Middle Name:
Other - Last Name:BUGBEE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:197 THOMAS JOHNSON DR STE B
Mailing Address - Street 2:
Mailing Address - City:FREDERICK
Mailing Address - State:MD
Mailing Address - Zip Code:21702-4314
Mailing Address - Country:US
Mailing Address - Phone:301-662-1997
Mailing Address - Fax:
Practice Address - Street 1:626 TRAIL AVE
Practice Address - Street 2:
Practice Address - City:FREDERICK
Practice Address - State:MD
Practice Address - Zip Code:21701
Practice Address - Country:US
Practice Address - Phone:301-662-1997
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-14
Last Update Date:2018-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD20331225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDS404-0021OtherCAREFIRST BC/BS
MDKBC4H0-62042205OtherBC/BS
DCG00930-018497H30Medicare PIN
MD167MM960Medicare PIN