Provider Demographics
NPI:1235003955
Name:CHURCO, KRISTEN NICHOLE (LMT)
Entity type:Individual
Prefix:
First Name:KRISTEN
Middle Name:NICHOLE
Last Name:CHURCO
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 1:26 FIRST ST
Mailing Address - Street 2:
Mailing Address - City:TUPPER LAKE
Mailing Address - State:NY
Mailing Address - Zip Code:12986-2006
Mailing Address - Country:US
Mailing Address - Phone:518-354-2868
Mailing Address - Fax:
Practice Address - Street 1:233 PARK ST
Practice Address - Street 2:
Practice Address - City:TUPPER LAKE
Practice Address - State:NY
Practice Address - Zip Code:12986-1933
Practice Address - Country:US
Practice Address - Phone:518-354-2868
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-10-04
Last Update Date:2025-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY29971225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist