Provider Demographics
NPI:1174860860
Name:DECKER, KRISTEN (DPT)
Entity Type:Individual
Prefix:
First Name:KRISTEN
Middle Name:
Last Name:DECKER
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:KRISTEN
Other - Middle Name:
Other - Last Name:EVEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DPT
Mailing Address - Street 1:17834 BEECHWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:BEVERLY HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48025-5528
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:26850 PROVIDENCE PKWY
Practice Address - Street 2:SUITE 365
Practice Address - City:NOVI
Practice Address - State:MI
Practice Address - Zip Code:48374-1213
Practice Address - Country:US
Practice Address - Phone:248-380-3550
Practice Address - Fax:248-380-1620
Is Sole Proprietor?:No
Enumeration Date:2013-01-15
Last Update Date:2013-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501016161225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
M77520021Medicare PIN