Provider Demographics
NPI:1962462770
Name:ALLEN, KRISTIN C (PT)
Entity Type:Individual
Prefix:
First Name:KRISTIN
Middle Name:C
Last Name:ALLEN
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 1:3317 HARVEST RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:HURON
Mailing Address - State:OH
Mailing Address - Zip Code:44839-1067
Mailing Address - Country:US
Mailing Address - Phone:419-557-2019
Mailing Address - Fax:
Practice Address - Street 1:134 EAST SHORELINE DRIVE
Practice Address - Street 2:
Practice Address - City:SANDUSKY
Practice Address - State:OH
Practice Address - Zip Code:44870
Practice Address - Country:US
Practice Address - Phone:419-557-2019
Practice Address - Fax:419-433-5509
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-24
Last Update Date:2019-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH22 030 630332B00000X, 332BC3200X
OHPT -5557335E00000X
OHPT-5557225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment
No335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH11550039OtherCAQH #
OH268 4877Medicaid
OH269 4679Medicaid
OHAL 418 6011Medicare ID - Type UnspecifiedINDIVIDUAL
OH5676960001Medicare NSC
OH11550039OtherCAQH #