Provider Demographics
NPI:1508006842
Name:LITTLE, KIERSTEN ELISE (PT, DPT)
Entity Type:Individual
Prefix:
First Name:KIERSTEN
Middle Name:ELISE
Last Name:LITTLE
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:KIERSTEN
Other - Middle Name:
Other - Last Name:GERBERICH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT, DPT
Mailing Address - Street 1:602 VONDERBURG DR
Mailing Address - Street 2:SUITE 201
Mailing Address - City:BRANDON
Mailing Address - State:FL
Mailing Address - Zip Code:33511-5900
Mailing Address - Country:US
Mailing Address - Phone:813-653-1149
Mailing Address - Fax:813-654-6644
Practice Address - Street 1:602 VONDERBURG DR
Practice Address - Street 2:SUITE 201
Practice Address - City:BRANDON
Practice Address - State:FL
Practice Address - Zip Code:33511-5900
Practice Address - Country:US
Practice Address - Phone:813-653-1149
Practice Address - Fax:813-654-6644
Is Sole Proprietor?:No
Enumeration Date:2009-02-26
Last Update Date:2011-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL24576225100000X
FLPTFL#24576225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLY06TPOtherBC-BS OF FLORIDA
FL002779700Medicaid
FLEY520ZMedicare PIN