Provider Demographics
NPI:1710966676
Name:FONTAINE, KRISTINE M (PT)
Entity Type:Individual
Prefix:
First Name:KRISTINE
Middle Name:M
Last Name:FONTAINE
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:630 PLANTATION ST
Mailing Address - Street 2:
Mailing Address - City:WORCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01605
Mailing Address - Country:US
Mailing Address - Phone:508-856-9510
Mailing Address - Fax:508-853-1907
Practice Address - Street 1:135 GOLD STAR BLVD
Practice Address - Street 2:
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01506
Practice Address - Country:US
Practice Address - Phone:508-856-9510
Practice Address - Fax:508-853-1907
Is Sole Proprietor?:No
Enumeration Date:2006-01-10
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA7353225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
042472266OtherHEALTHCARE VALUE MNGEMENT
042472266OtherONE HEALTH PLAN
Y66516OtherBLUE CARE ELECT
042472266OtherPRIVATE HEALTHCARE SYSTEM
AA4052OtherHARVARD PILGRIM HLTHCARE
Y66516OtherBLUE SHIELD INDEMNITY
650017419OtherRAILROAD MEDICARE
2779432OtherCIGNA HEALTH PLAN
785954OtherMVP HEALTH CARE
Y66516OtherBLUE SHIELD HMO BLUE
0318876OtherMEDICAID/WELFARE
44338OtherFALLON COMMUNITY HLTH PLN
5238453OtherAETNA/US HEALTHCARE
35481155OtherCIGNA HEALTHSOURCE
Y69458OtherMEDICARE B
MA0318876Medicaid
042472266OtherTHREE RIVERS
2779432001OtherCOGMA A; OD (REFERRAL #)
MAY69458Medicare ID - Type Unspecified