Provider Demographics
NPI:1932798915
Name:RIDEOUT, KRISTA LYNN (LMT)
Entity Type:Individual
Prefix:
First Name:KRISTA
Middle Name:LYNN
Last Name:RIDEOUT
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:47 VANNER RD
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:ME
Mailing Address - Zip Code:04574-3636
Mailing Address - Country:US
Mailing Address - Phone:207-615-4768
Mailing Address - Fax:
Practice Address - Street 1:724 COMMERCIAL ST
Practice Address - Street 2:
Practice Address - City:ROCKPORT
Practice Address - State:ME
Practice Address - Zip Code:04856-4201
Practice Address - Country:US
Practice Address - Phone:207-615-4768
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-13
Last Update Date:2021-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEMT4561225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist