Provider Demographics
NPI:1679618144
Name:BACON, KRISTIN M (PT)
Entity Type:Individual
Prefix:
First Name:KRISTIN
Middle Name:M
Last Name:BACON
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:KIDABILITY
Other - Middle Name:PHYSICAL
Other - Last Name:THERAPY, LLC
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 112693
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99511-2693
Mailing Address - Country:US
Mailing Address - Phone:907-770-5557
Mailing Address - Fax:907-770-5755
Practice Address - Street 1:12801 JEANNE RD
Practice Address - Street 2:
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99516-3347
Practice Address - Country:US
Practice Address - Phone:907-230-0402
Practice Address - Fax:907-770-5755
Is Sole Proprietor?:No
Enumeration Date:2007-02-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK11592251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKPT9331Medicaid
AK419964OtherBUSINESS LICENSE