Healthcare Provider Details

I. General information

NPI: 1083697346
Provider Name (Legal Business Name): KRISTINA DIANE MATTHEWS MPT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: KRISTINA DIANE PORTER MPT

II. Dates (important events)

Enumeration Date: 11/21/2005
Last Update Date: 05/21/2024
Certification Date: 05/21/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

74 JOURNEY WAY
VALPARAISO IN
46383-0078
US

IV. Provider business mailing address

5214 S EAST ST BUILDING D SUITE 1
INDIANAPOLIS IN
46227-1917
US

V. Phone/Fax

Practice location:
  • Phone: 219-255-4378
  • Fax:
Mailing address:
  • Phone: 800-486-4449
  • Fax: 317-780-3745

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number004686
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: