Provider Demographics
NPI:1134408321
Name:KORTH, KRISTIN JEAN (OT)
Entity type:Individual
Prefix:
First Name:KRISTIN
Middle Name:JEAN
Last Name:KORTH
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:134 N 248TH CIR
Mailing Address - Street 2:
Mailing Address - City:WATERLOO
Mailing Address - State:NE
Mailing Address - Zip Code:68069-4690
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:134 N 248TH CIR
Practice Address - Street 2:
Practice Address - City:WATERLOO
Practice Address - State:NE
Practice Address - Zip Code:68069-4690
Practice Address - Country:US
Practice Address - Phone:402-740-8136
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-05
Last Update Date:2011-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE900984225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist