Provider Demographics
NPI:1598792855
Name:BANSE, KRISTIN E (PT)
Entity Type:Individual
Prefix:
First Name:KRISTIN
Middle Name:E
Last Name:BANSE
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20 WALNUT STREET
Mailing Address - Street 2:SUITE B
Mailing Address - City:MONTGOMERY
Mailing Address - State:NY
Mailing Address - Zip Code:12549
Mailing Address - Country:US
Mailing Address - Phone:845-457-5555
Mailing Address - Fax:845-457-5556
Practice Address - Street 1:181 JERSEY AVENUE
Practice Address - Street 2:
Practice Address - City:PORT JERVIS
Practice Address - State:NY
Practice Address - Zip Code:12771
Practice Address - Country:US
Practice Address - Phone:845-858-9999
Practice Address - Fax:845-858-9998
Is Sole Proprietor?:No
Enumeration Date:2006-06-26
Last Update Date:2008-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY012003225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYQ00941Medicare PIN