Provider Demographics
NPI:1346565678
Name:PERINE, KRISTA SUZANNE
Entity Type:Individual
Prefix:MS
First Name:KRISTA
Middle Name:SUZANNE
Last Name:PERINE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1713 PEMBROOK CT
Mailing Address - Street 2:
Mailing Address - City:PLAINFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:60586-9784
Mailing Address - Country:US
Mailing Address - Phone:815-355-4165
Mailing Address - Fax:
Practice Address - Street 1:1713 PEMBROOK CT
Practice Address - Street 2:
Practice Address - City:PLAINFIELD
Practice Address - State:IL
Practice Address - Zip Code:60586-9784
Practice Address - Country:US
Practice Address - Phone:815-355-4165
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-30
Last Update Date:2010-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL222Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist