Basic Information
| Provider Information | |||||||||
| NPI: | 1659337327 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DUTTON | ||||||||
| FirstName: | CHRISTINA | ||||||||
| MiddleName: | KILLCREAS | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MSPT | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | DUTTON | ||||||||
| OtherFirstName: | CHRISTY | ||||||||
| OtherMiddleName: | KILLCREAS | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | MSPT | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2147 RIVERCHASE OFFICE RD | ||||||||
| Address2: | |||||||||
| City: | BIRMINGHAM | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 35244 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2054038902 | ||||||||
| FaxNumber: | 2059827882 | ||||||||
| Practice Location | |||||||||
| Address1: | 1682 MONTGOMERY HWY | ||||||||
| Address2: | |||||||||
| City: | BIRMINGHAM | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 35216 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2054210000 | ||||||||
| FaxNumber: | 2054212016 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/21/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | PTH2391 | AL | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | PPT | 01 | AL | BLUE CROSS BLUE SHIELD | OTHER | 7689071 | 01 | AL | AETNA | OTHER |