Provider Demographics
NPI:1205966165
Name:ANDREAE, KRISTIN DIANE WODZINSKI (MS, PT)
Entity type:Individual
Prefix:MISS
First Name:KRISTIN
Middle Name:DIANE WODZINSKI
Last Name:ANDREAE
Suffix:
Gender:F
Credentials:MS, PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1455 W FAIR AVE
Mailing Address - Street 2:
Mailing Address - City:MARQUETTE
Mailing Address - State:MI
Mailing Address - Zip Code:49855-2654
Mailing Address - Country:US
Mailing Address - Phone:616-460-0689
Mailing Address - Fax:
Practice Address - Street 1:1455 W FAIR AVE
Practice Address - Street 2:
Practice Address - City:MARQUETTE
Practice Address - State:MI
Practice Address - Zip Code:49855-2654
Practice Address - Country:US
Practice Address - Phone:616-460-0689
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-07
Last Update Date:2016-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501011205225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0E20191OtherBCBS INDIVIDUAL
MI0E20057OtherBCBS GROUP PT
MI0E20057OtherBCBS GROUP PT