Provider Demographics
NPI:1992826119
Name:JOHANSEN, KRISTEN MARIE (DC)
Entity Type:Individual
Prefix:
First Name:KRISTEN
Middle Name:MARIE
Last Name:JOHANSEN
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:KRISTEN
Other - Middle Name:MARIE
Other - Last Name:GUSTAFSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DC
Mailing Address - Street 1:6852 W 111TH ST
Mailing Address - Street 2:
Mailing Address - City:WORTH
Mailing Address - State:IL
Mailing Address - Zip Code:60482-1823
Mailing Address - Country:US
Mailing Address - Phone:708-448-3818
Mailing Address - Fax:708-448-3804
Practice Address - Street 1:6852 W 111TH ST
Practice Address - Street 2:
Practice Address - City:WORTH
Practice Address - State:IL
Practice Address - Zip Code:60482-1823
Practice Address - Country:US
Practice Address - Phone:708-448-3818
Practice Address - Fax:708-448-3804
Is Sole Proprietor?:No
Enumeration Date:2007-04-03
Last Update Date:2009-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038-008775111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILU78825Medicare UPIN