Provider Demographics
NPI:1669807681
Name:MCPEAK, KRISTINE SUE (PTA)
Entity type:Individual
Prefix:
First Name:KRISTINE
Middle Name:SUE
Last Name:MCPEAK
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:612A WILLOW RD APT 6
Mailing Address - Street 2:
Mailing Address - City:MARQUETTE
Mailing Address - State:MI
Mailing Address - Zip Code:49855-9300
Mailing Address - Country:US
Mailing Address - Phone:906-869-4953
Mailing Address - Fax:
Practice Address - Street 1:612A WILLOW RD APT 6
Practice Address - Street 2:
Practice Address - City:MARQUETTE
Practice Address - State:MI
Practice Address - Zip Code:49855-9300
Practice Address - Country:US
Practice Address - Phone:906-869-4953
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-09-10
Last Update Date:2013-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIL2529111225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant