Provider Demographics
NPI:1205588183
Name:KRIEGBAUM, MINDY (LMT)
Entity type:Individual
Prefix:
First Name:MINDY
Middle Name:
Last Name:KRIEGBAUM
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4080 MARSHALL RD STE 101
Mailing Address - Street 2:
Mailing Address - City:KETTERING
Mailing Address - State:OH
Mailing Address - Zip Code:45429-5157
Mailing Address - Country:US
Mailing Address - Phone:937-241-5173
Mailing Address - Fax:937-567-0716
Practice Address - Street 1:4080 MARSHALL RD STE 101
Practice Address - Street 2:
Practice Address - City:KETTERING
Practice Address - State:OH
Practice Address - Zip Code:45429-5157
Practice Address - Country:US
Practice Address - Phone:937-241-5173
Practice Address - Fax:937-567-0716
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-22
Last Update Date:2022-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH33.023871225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist