Provider Demographics
NPI:1922564582
Name:GULLEN, KRISTIN MICHELLE (DPT)
Entity Type:Individual
Prefix:MRS
First Name:KRISTIN
Middle Name:MICHELLE
Last Name:GULLEN
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:MRS
Other - First Name:KRISSY
Other - Middle Name:MICHELLE
Other - Last Name:GULLEN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DPT
Mailing Address - Street 1:750 W ROUTE 66 STE N
Mailing Address - Street 2:
Mailing Address - City:GLENDORA
Mailing Address - State:CA
Mailing Address - Zip Code:91740-4164
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:750 W ROUTE 66 STE N
Practice Address - Street 2:
Practice Address - City:GLENDORA
Practice Address - State:CA
Practice Address - Zip Code:91740-4164
Practice Address - Country:US
Practice Address - Phone:626-335-4077
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-19
Last Update Date:2019-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA296340225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist