Provider Demographics
NPI:1790873651
Name:THORESEN, CRISTA (PT)
Entity Type:Individual
Prefix:
First Name:CRISTA
Middle Name:
Last Name:THORESEN
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:CRISTA
Other - Middle Name:
Other - Last Name:LAWRENCE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:1600 BALLEWTOWN RD
Mailing Address - Street 2:
Mailing Address - City:BLUE RIDGE
Mailing Address - State:GA
Mailing Address - Zip Code:30513-5337
Mailing Address - Country:US
Mailing Address - Phone:706-621-5686
Mailing Address - Fax:706-621-5689
Practice Address - Street 1:1600 BALLEWTOWN RD
Practice Address - Street 2:
Practice Address - City:BLUE RIDGE
Practice Address - State:GA
Practice Address - Zip Code:30513-5337
Practice Address - Country:US
Practice Address - Phone:706-621-5686
Practice Address - Fax:706-621-5689
Is Sole Proprietor?:No
Enumeration Date:2006-10-10
Last Update Date:2022-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA7312225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist