Provider Demographics
NPI:1629152665
Name:DUMFORD, KIRSTEN
Entity Type:Individual
Prefix:
First Name:KIRSTEN
Middle Name:
Last Name:DUMFORD
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 1:2039 CRINELLA DR
Mailing Address - Street 2:
Mailing Address - City:PETALUMA
Mailing Address - State:CA
Mailing Address - Zip Code:94954-5627
Mailing Address - Country:US
Mailing Address - Phone:415-847-2097
Mailing Address - Fax:415-893-9931
Practice Address - Street 1:46 TRINITY DR
Practice Address - Street 2:
Practice Address - City:NOVATO
Practice Address - State:CA
Practice Address - Zip Code:94947-5245
Practice Address - Country:US
Practice Address - Phone:415-847-2097
Practice Address - Fax:415-893-9931
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-25
Last Update Date:2016-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT20442225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA0PT204421OtherMEDICARE PIN NUMBER
CA0PT204421Medicare PIN