Provider Demographics
NPI:1669035895
Name:ROBERTS, KRISTINE ANNA (LMT)
Entity Type:Individual
Prefix:
First Name:KRISTINE
Middle Name:ANNA
Last Name:ROBERTS
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:KRISTINE
Other - Middle Name:ANNA
Other - Last Name:ROBERTS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LMT
Mailing Address - Street 1:3175 CHRISTY WAY S STE 8
Mailing Address - Street 2:
Mailing Address - City:SAGINAW
Mailing Address - State:MI
Mailing Address - Zip Code:48603-2210
Mailing Address - Country:US
Mailing Address - Phone:989-522-2552
Mailing Address - Fax:
Practice Address - Street 1:3175 CHRISTY WAY 8
Practice Address - Street 2:
Practice Address - City:SAGINAW
Practice Address - State:MI
Practice Address - Zip Code:48603
Practice Address - Country:US
Practice Address - Phone:989-522-2552
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-14
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI7501005349225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist