Provider Demographics
NPI:1598837916
Name:KING, KRISTEN E (PT)
Entity Type:Individual
Prefix:
First Name:KRISTEN
Middle Name:E
Last Name:KING
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:KRISTEN
Other - Middle Name:E
Other - Last Name:YATES
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:
Practice Address - Street 1:103 N MAIN ST
Practice Address - Street 2:STE 300
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29601-2796
Practice Address - Country:US
Practice Address - Phone:864-528-5728
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-14
Last Update Date:2015-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC5379225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCTH1767Medicaid
SCQ34360Medicare UPIN