Provider Demographics
NPI:1013056613
Name:SELBITSCHKA, KRISTA MEGAN (PTA)
Entity type:Individual
Prefix:
First Name:KRISTA
Middle Name:MEGAN
Last Name:SELBITSCHKA
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6437 TOMAHAWK TRL
Mailing Address - Street 2:
Mailing Address - City:LINO LAKES
Mailing Address - State:MN
Mailing Address - Zip Code:55014-1458
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:295 PHALEN BLVD
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55130-2400
Practice Address - Country:US
Practice Address - Phone:651-524-0719
Practice Address - Fax:651-254-3212
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-06
Last Update Date:2013-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNA1084225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant