Provider Demographics
NPI:1144775784
Name:SOMERVILLE, KRISTIN MARIE (DPT)
Entity Type:Individual
Prefix:
First Name:KRISTIN
Middle Name:MARIE
Last Name:SOMERVILLE
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 1:150 GENTILLY BLVD
Mailing Address - Street 2:
Mailing Address - City:CARTERSVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30120-8522
Mailing Address - Country:US
Mailing Address - Phone:678-403-3632
Mailing Address - Fax:
Practice Address - Street 1:2824 ROGERS RD STE 102
Practice Address - Street 2:
Practice Address - City:WAKE FOREST
Practice Address - State:NC
Practice Address - Zip Code:27587-3896
Practice Address - Country:US
Practice Address - Phone:919-229-8363
Practice Address - Fax:919-229-8356
Is Sole Proprietor?:No
Enumeration Date:2016-08-24
Last Update Date:2019-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT012526225100000X
NC225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist