Provider Demographics
NPI:1942396668
Name:PETERSON, KRISTINA ANNA GLAD (DPT)
Entity Type:Individual
Prefix:MS
First Name:KRISTINA
Middle Name:ANNA GLAD
Last Name:PETERSON
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:MISS
Other - First Name:KRISTINA
Other - Middle Name:ANNA
Other - Last Name:GLALD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DPT
Mailing Address - Street 1:5925 SYCAMORE CANYON BLVD APT 116
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92507-8467
Mailing Address - Country:US
Mailing Address - Phone:951-686-5828
Mailing Address - Fax:
Practice Address - Street 1:6177 RIVER CREST DR STE A
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92507-0728
Practice Address - Country:US
Practice Address - Phone:951-653-4480
Practice Address - Fax:951-653-5051
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2008-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT 33079225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPT33079OtherSTATE LICENSE
CAZZZ17185ZMedicare PIN