Provider Demographics
NPI:1760726053
Name:WITHERS, KRISTINA L (DPT)
Entity Type:Individual
Prefix:
First Name:KRISTINA
Middle Name:L
Last Name:WITHERS
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:KRISTINA
Other - Middle Name:L
Other - Last Name:WANOUS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DPT
Mailing Address - Street 1:4200 DAHLBERG DR
Mailing Address - Street 2:SUITE 300
Mailing Address - City:GOLDEN VALLEY
Mailing Address - State:MN
Mailing Address - Zip Code:55422-4840
Mailing Address - Country:US
Mailing Address - Phone:952-512-5600
Mailing Address - Fax:952-512-5651
Practice Address - Street 1:8290 UNIVERSITY AVE NE
Practice Address - Street 2:SUITE 200
Practice Address - City:FRIDLEY
Practice Address - State:MN
Practice Address - Zip Code:55432-1847
Practice Address - Country:US
Practice Address - Phone:763-786-9543
Practice Address - Fax:763-786-3320
Is Sole Proprietor?:No
Enumeration Date:2012-11-27
Last Update Date:2016-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN96072251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic