Provider Demographics
NPI:1609021559
Name:COBURN, KRYSTIN MARIE (OTR/L)
Entity Type:Individual
Prefix:
First Name:KRYSTIN
Middle Name:MARIE
Last Name:COBURN
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:314 SUNSET AVE
Mailing Address - Street 2:
Mailing Address - City:GLENDIVE
Mailing Address - State:MT
Mailing Address - Zip Code:59330-2839
Mailing Address - Country:US
Mailing Address - Phone:406-365-7023
Mailing Address - Fax:
Practice Address - Street 1:641 33RD AVE NE
Practice Address - Street 2:
Practice Address - City:GREAT FALLS
Practice Address - State:MT
Practice Address - Zip Code:59404-1114
Practice Address - Country:US
Practice Address - Phone:406-952-1450
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-11-19
Last Update Date:2009-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT1056225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist