Provider Demographics
NPI:1871587162
Name:KVISTBERG BECKER, KRISTINE CARRIE (ATC)
Entity type:Individual
Prefix:
First Name:KRISTINE
Middle Name:CARRIE
Last Name:KVISTBERG BECKER
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5144 38TH AVE S
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55417-1650
Mailing Address - Country:US
Mailing Address - Phone:612-721-6295
Mailing Address - Fax:
Practice Address - Street 1:1280 DISC DR
Practice Address - Street 2:
Practice Address - City:SHAKOPEE
Practice Address - State:MN
Practice Address - Zip Code:55379-1863
Practice Address - Country:US
Practice Address - Phone:952-402-3480
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-09-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN13782255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer