Provider Demographics
NPI:1235147851
Name:BIRCH, KRISTINA NIELSEN (DPT)
Entity Type:Individual
Prefix:
First Name:KRISTINA
Middle Name:NIELSEN
Last Name:BIRCH
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:KRISTINA
Other - Middle Name:KIMBERLY
Other - Last Name:NIELSEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DPT
Mailing Address - Street 1:20781 N MEADOW LN
Mailing Address - Street 2:
Mailing Address - City:DEER PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60010-3627
Mailing Address - Country:US
Mailing Address - Phone:737-472-2731
Mailing Address - Fax:
Practice Address - Street 1:2533 N SOUTHPORT AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60614-7166
Practice Address - Country:US
Practice Address - Phone:773-472-2731
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-03
Last Update Date:2023-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070014354225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL202421Medicare ID - Type Unspecified