Healthcare Provider Details

I. General information

NPI: 1093911968
Provider Name (Legal Business Name): KRISTINA MARGARET MARCUSSEN PT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/26/2007
Last Update Date: 08/23/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21 GREGORY DR
SOUTH BURLINGTON VT
05403-6080
US

IV. Provider business mailing address

73 MCCLELLAN FARM RD
UNDERHILL VT
05489-9421
US

V. Phone/Fax

Practice location:
  • Phone: 802-658-0949
  • Fax: 802-658-1436
Mailing address:
  • Phone: 773-458-0183
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number040-0003702
License Number StateVT
# 2
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number12405
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: