Provider Demographics
NPI:1679016562
Name:TISHER, KRISTEN BLAIR (PT, DPT)
Entity Type:Individual
Prefix:
First Name:KRISTEN
Middle Name:BLAIR
Last Name:TISHER
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 242
Mailing Address - Street 2:
Mailing Address - City:LANGFORD
Mailing Address - State:SD
Mailing Address - Zip Code:57454-0242
Mailing Address - Country:US
Mailing Address - Phone:801-518-5521
Mailing Address - Fax:
Practice Address - Street 1:1311 VANDER HORCK ST
Practice Address - Street 2:
Practice Address - City:BRITTON
Practice Address - State:SD
Practice Address - Zip Code:57430-2254
Practice Address - Country:US
Practice Address - Phone:605-448-2251
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-11-23
Last Update Date:2016-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD1879225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist