Provider Demographics
NPI:1669422366
Name:TASKA, KRISTIN COURTNEY (PT)
Entity type:Individual
Prefix:
First Name:KRISTIN
Middle Name:COURTNEY
Last Name:TASKA
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:KRISTIN
Other - Middle Name:P
Other - Last Name:COURTNEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 749306
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-9306
Mailing Address - Country:US
Mailing Address - Phone:843-443-9368
Mailing Address - Fax:
Practice Address - Street 1:2050 CORPORATE CENTRE DR
Practice Address - Street 2:
Practice Address - City:MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29577-7428
Practice Address - Country:US
Practice Address - Phone:843-443-9368
Practice Address - Fax:843-916-2348
Is Sole Proprietor?:No
Enumeration Date:2006-05-11
Last Update Date:2024-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC4889225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
Q21594Medicare UPIN
Q33651Medicare ID - Type Unspecified