Provider Demographics
NPI:1811337082
Name:ANDERSON, KRISTIN MICHELE (DPT)
Entity type:Individual
Prefix:
First Name:KRISTIN
Middle Name:MICHELE
Last Name:ANDERSON
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 1:4326 CAHUENGA BLVD
Mailing Address - Street 2:APT 7
Mailing Address - City:TOLUCA LAKE
Mailing Address - State:CA
Mailing Address - Zip Code:91602-2765
Mailing Address - Country:US
Mailing Address - Phone:661-877-7389
Mailing Address - Fax:
Practice Address - Street 1:488 S SAN VICENTE BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90048-4107
Practice Address - Country:US
Practice Address - Phone:323-655-9055
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-07-02
Last Update Date:2015-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA40374225100000X
225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist