Provider Demographics
NPI:1407260367
Name:SHUPERT, KRISTINA (MS, OTR/L)
Entity Type:Individual
Prefix:
First Name:KRISTINA
Middle Name:
Last Name:SHUPERT
Suffix:
Gender:F
Credentials:MS, OTR/L
Other - Prefix:
Other - First Name:KRISTINA
Other - Middle Name:
Other - Last Name:ETHRIDGE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4560 SOUTH BLVD
Mailing Address - Street 2:SUITE 310
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23452-1160
Mailing Address - Country:US
Mailing Address - Phone:757-490-3223
Mailing Address - Fax:757-490-2936
Practice Address - Street 1:4560 SOUTH BLVD
Practice Address - Street 2:SUITE 310
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23452-1160
Practice Address - Country:US
Practice Address - Phone:757-490-3223
Practice Address - Fax:757-490-2936
Is Sole Proprietor?:No
Enumeration Date:2014-06-18
Last Update Date:2016-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0119006226225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0119006226OtherSTATE LICENSURE