Provider Demographics
NPI:1770693509
Name:KOCH, KRISTINA MARIE (MPT)
Entity type:Individual
Prefix:MRS
First Name:KRISTINA
Middle Name:MARIE
Last Name:KOCH
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:KRISTINA
Other - Middle Name:MARIE
Other - Last Name:GRAY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MPT
Mailing Address - Street 1:13085 CRANE CANYON LOOP
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80921-7217
Mailing Address - Country:US
Mailing Address - Phone:619-578-4362
Mailing Address - Fax:
Practice Address - Street 1:5265 N ACADEMY BLVD
Practice Address - Street 2:#1500
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80918-4060
Practice Address - Country:US
Practice Address - Phone:719-694-8342
Practice Address - Fax:719-694-8347
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2017-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT25297225100000X, 2251G0304X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2251G0304XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGeriatrics