Provider Demographics
NPI:1831366053
Name:AULT, KIRSTEN E (PTA)
Entity type:Individual
Prefix:
First Name:KIRSTEN
Middle Name:E
Last Name:AULT
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 1:9418 W COUNTY ROAD 300 S
Mailing Address - Street 2:
Mailing Address - City:MEDORA
Mailing Address - State:IN
Mailing Address - Zip Code:47260-9709
Mailing Address - Country:US
Mailing Address - Phone:812-521-0054
Mailing Address - Fax:812-966-2407
Practice Address - Street 1:9418 W COUNTY ROAD 300 S
Practice Address - Street 2:
Practice Address - City:MEDORA
Practice Address - State:IN
Practice Address - Zip Code:47260-9709
Practice Address - Country:US
Practice Address - Phone:812-521-0054
Practice Address - Fax:812-966-2407
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-15
Last Update Date:2008-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN06003508A174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist