Provider Demographics
NPI:1164575791
Name:KECK, KRISTA LEE (PT)
Entity Type:Individual
Prefix:
First Name:KRISTA
Middle Name:LEE
Last Name:KECK
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 1:10560 APPLEWOOD DR
Mailing Address - Street 2:
Mailing Address - City:SISTER BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54234-9005
Mailing Address - Country:US
Mailing Address - Phone:920-854-4111
Mailing Address - Fax:
Practice Address - Street 1:10560 APPLEWOOD DR
Practice Address - Street 2:
Practice Address - City:SISTER BAY
Practice Address - State:WI
Practice Address - Zip Code:54234-9005
Practice Address - Country:US
Practice Address - Phone:920-854-4111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-18
Last Update Date:2014-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI12522-24225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1164575791Medicaid
WA0039622OtherLABOR AND INDUSTRIES#