Provider Demographics
NPI:1417423740
Name:SOUDER, KRISTEN (PTA)
Entity Type:Individual
Prefix:
First Name:KRISTEN
Middle Name:
Last Name:SOUDER
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:580 EBRITE RD
Mailing Address - Street 2:
Mailing Address - City:WEST UNION
Mailing Address - State:OH
Mailing Address - Zip Code:45693-9709
Mailing Address - Country:US
Mailing Address - Phone:937-515-0997
Mailing Address - Fax:
Practice Address - Street 1:2003 VETERANS BLVD
Practice Address - Street 2:
Practice Address - City:GEORGETOWN
Practice Address - State:OH
Practice Address - Zip Code:45121-7408
Practice Address - Country:US
Practice Address - Phone:937-515-0997
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-14
Last Update Date:2018-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH005562225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant