Basic Information
| Provider Information | |||||||||
| NPI: | 1619361391 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SHOWALTER | ||||||||
| FirstName: | KRISTEN | ||||||||
| MiddleName: | HEATHER | ||||||||
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| Credential: | OTR/L, LMT | ||||||||
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| OtherLastName: | SHOWALTER | ||||||||
| OtherFirstName: | KRISHA | ||||||||
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| OtherCredential: | OTR/L, LMT | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 4 LOUISE PL | ||||||||
| Address2: | |||||||||
| City: | STAATSBURG | ||||||||
| State: | NY | ||||||||
| PostalCode: | 125806124 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6462346729 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3840 HULEN ST | ||||||||
| Address2: | |||||||||
| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761077277 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8175694300 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/20/2015 | ||||||||
| LastUpdateDate: | 12/10/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225700000X | 016038 | NY | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Massage Therapist | 225X00000X | 018022 | NY | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | 225X00000X | 118574 | TX | Y | 193400000X SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |
No ID Information.