Provider Demographics
NPI:1609297043
Name:WILBRAHAM, KRISTINA
Entity Type:Individual
Prefix:MRS
First Name:KRISTINA
Middle Name:
Last Name:WILBRAHAM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5554 CHRISTINA PATH
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78247-6611
Mailing Address - Country:US
Mailing Address - Phone:210-687-5912
Mailing Address - Fax:
Practice Address - Street 1:21 SPURS LN
Practice Address - Street 2:SUITE 246 & 320
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78240-1669
Practice Address - Country:US
Practice Address - Phone:210-487-7463
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-03
Last Update Date:2014-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXMT110421225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist