Provider Demographics
NPI:1477655132
Name:IMESCH, KRISTYN ANN (MSPT)
Entity Type:Individual
Prefix:
First Name:KRISTYN
Middle Name:ANN
Last Name:IMESCH
Suffix:
Gender:F
Credentials:MSPT
Other - Prefix:
Other - First Name:KRISTYN
Other - Middle Name:ANN
Other - Last Name:KLEZEK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:283 MERRIWEATHER RD
Mailing Address - Street 2:
Mailing Address - City:GROSSE POINTE FARMS
Mailing Address - State:MI
Mailing Address - Zip Code:48236-3428
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:24715 LITTLE MACK AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:SAINT CLAIR SHORES
Practice Address - State:MI
Practice Address - Zip Code:48080-3207
Practice Address - Country:US
Practice Address - Phone:586-779-2585
Practice Address - Fax:586-779-7748
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501009543225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist