Provider Demographics
NPI:1851633739
Name:DIVICO, KRISTINA M (DPT)
Entity Type:Individual
Prefix:DR
First Name:KRISTINA
Middle Name:M
Last Name:DIVICO
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:715 COHASSET CT
Mailing Address - Street 2:APT 15
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92109-8142
Mailing Address - Country:US
Mailing Address - Phone:206-661-1501
Mailing Address - Fax:
Practice Address - Street 1:404 CAMINO DEL RIO S
Practice Address - Street 2:SUITE 508
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92108-3503
Practice Address - Country:US
Practice Address - Phone:619-325-0154
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-03-19
Last Update Date:2013-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA39995225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist