Provider Demographics
NPI:1700576865
Name:DIBERNARDO, KRISTEN (DPT)
Entity Type:Individual
Prefix:
First Name:KRISTEN
Middle Name:
Last Name:DIBERNARDO
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3018 DELUNA DR
Mailing Address - Street 2:
Mailing Address - City:RANCHO PALOS VERDES
Mailing Address - State:CA
Mailing Address - Zip Code:90275-6303
Mailing Address - Country:US
Mailing Address - Phone:310-606-1715
Mailing Address - Fax:
Practice Address - Street 1:172 LAWRENCE ST
Practice Address - Street 2:
Practice Address - City:LAWRENCE
Practice Address - State:MA
Practice Address - Zip Code:01841-3849
Practice Address - Country:US
Practice Address - Phone:978-685-6321
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-11
Last Update Date:2024-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA304040225100000X
MA27531225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist