Provider Demographics
NPI:1790076040
Name:KEDERSHA, KRISTEN L (PT)
Entity Type:Individual
Prefix:
First Name:KRISTEN
Middle Name:L
Last Name:KEDERSHA
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 1:1318 CHEYENNE DR
Mailing Address - Street 2:
Mailing Address - City:RICHARDSON
Mailing Address - State:TX
Mailing Address - Zip Code:75080-3705
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:411 N WASHINGTON AVE STE 4000
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75246-1776
Practice Address - Country:US
Practice Address - Phone:214-820-9393
Practice Address - Fax:214-820-8877
Is Sole Proprietor?:No
Enumeration Date:2011-04-20
Last Update Date:2011-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1145050225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist