Provider Demographics
NPI:1558677302
Name:FOSBERG, KIRSTIN ANNE
Entity Type:Individual
Prefix:
First Name:KIRSTIN
Middle Name:ANNE
Last Name:FOSBERG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KIRSTIN
Other - Middle Name:ANNE
Other - Last Name:HOPKINS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:790 REMINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60440-4909
Mailing Address - Country:US
Mailing Address - Phone:630-296-2223
Mailing Address - Fax:630-759-9510
Practice Address - Street 1:6601 220TH ST SW
Practice Address - Street 2:STE 1
Practice Address - City:MOUNTLAKE TERRACE
Practice Address - State:WA
Practice Address - Zip Code:98043-2166
Practice Address - Country:US
Practice Address - Phone:425-775-7274
Practice Address - Fax:425-775-0963
Is Sole Proprietor?:No
Enumeration Date:2010-08-30
Last Update Date:2015-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT00005491225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1558677302Medicaid
WA0290893OtherDEPT. OF LABOR AND INDUSTRIES
WAG8897632Medicare PIN