Provider Demographics
NPI:1861077067
Name:MASTERSON, KRISTEN MICHELLE (DPT)
Entity type:Individual
Prefix:
First Name:KRISTEN
Middle Name:MICHELLE
Last Name:MASTERSON
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:KRISTEN
Other - Middle Name:MICHELLE
Other - Last Name:MASTERSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DPT
Mailing Address - Street 1:PO BOX 5545
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30916-5545
Mailing Address - Country:US
Mailing Address - Phone:803-349-4118
Mailing Address - Fax:
Practice Address - Street 1:1504 CAROLNA PLACE DR STE 114
Practice Address - Street 2:
Practice Address - City:FORT MILL
Practice Address - State:SC
Practice Address - Zip Code:29708-7058
Practice Address - Country:US
Practice Address - Phone:803-349-3449
Practice Address - Fax:803-753-8476
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-10
Last Update Date:2021-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC10587208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty