Provider Demographics
NPI:1750806824
Name:ANSELMO, KRISTYN PATRICIA (DPT)
Entity type:Individual
Prefix:
First Name:KRISTYN
Middle Name:PATRICIA
Last Name:ANSELMO
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 1:12729 RIVERSIDE DR APT 109
Mailing Address - Street 2:
Mailing Address - City:VALLEY VILLAGE
Mailing Address - State:CA
Mailing Address - Zip Code:91607-3368
Mailing Address - Country:US
Mailing Address - Phone:201-704-3783
Mailing Address - Fax:
Practice Address - Street 1:101 HODENCAMP RD STE 102
Practice Address - Street 2:
Practice Address - City:THOUSAND OAKS
Practice Address - State:CA
Practice Address - Zip Code:91360-5831
Practice Address - Country:US
Practice Address - Phone:805-496-9944
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-09
Last Update Date:2017-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT293065225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist