Healthcare Provider Details

I. General information

NPI: 1174874085
Provider Name (Legal Business Name): KRISTA JACLYN DUGAN MPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/02/2012
Last Update Date: 10/02/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3000 BETHEL RD
COLUMBUS OH
43220-2262
US

IV. Provider business mailing address

1193 DOVER AVE
GRANDVIEW HEIGHTS OH
43212-3617
US

V. Phone/Fax

Practice location:
  • Phone: 614-889-6320
  • Fax:
Mailing address:
  • Phone: 614-832-2225
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251G0304X
TaxonomyGeriatric Physical Therapist
License Number10704
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code2251G0304X
TaxonomyGeriatric Physical Therapist
License Number1866
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: