{
"Npi": {
"NPI": "1477655132",
"EntityType": "Individual",
"ReplacementNPI": null,
"EIN": null,
"IsSoleProprietor": "Y",
"IsOrgSubpart": null,
"ParentOrgLBN": null,
"ParentOrgTIN": null,
"OrgName": null,
"LastName": "IMESCH",
"FirstName": "KRISTYN",
"MiddleName": "ANN",
"NamePrefix": null,
"NameSuffix": null,
"Credential": "MSPT",
"OtherOrgName": null,
"OtherOrgNameTypeCode": null,
"OtherLastName": "KLEZEK",
"OtherFirstName": "KRISTYN",
"OtherMiddleName": "ANN",
"OtherNamePrefix": null,
"OtherNameSuffix": null,
"OtherCredential": null,
"OtherLastNameTypeCode": "1",
"FirstLineMailingAddress": "283 MERRIWEATHER RD",
"SecondLineMailingAddress": null,
"MailingAddressCityName": "GROSSE POINTE FARMS",
"MailingAddressStateName": "MI",
"MailingAddressPostalCode": "48236-3428",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": null,
"MailingAddressFaxNumber": null,
"FirstLinePracticeLocationAddress": "24715 LITTLE MACK AVE",
"SecondLinePracticeLocationAddress": "SUITE 100",
"PracticeLocationAddressCityName": "SAINT CLAIR SHORES",
"PracticeLocationAddressStateName": "MI",
"PracticeLocationAddressPostalCode": "48080-3207",
"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "586-779-2585",
"PracticeLocationAddressFaxNumber": "586-779-7748",
"EnumerationDate": "09/02/2006",
"LastUpdateDate": "07/08/2007",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": "F",
"Gender": "Female",
"AuthorizedOfficialLastName": null,
"AuthorizedOfficialFirstName": null,
"AuthorizedOfficialMiddleName": null,
"AuthorizedOfficialTitle": null,
"AuthorizedOfficialNamePrefix": null,
"AuthorizedOfficialNameSuffix": null,
"AuthorizedOfficialCredential": null,
"AuthorizedOfficialTelephoneNumber": null,
"Taxonomies": {
"Taxonomy": {
"TaxonomyCode": "225100000X",
"TaxonomyName": "Physical Therapist",
"LicenseNumber": "5501009543",
"LicenseNumberStateCode": "MI",
"PrimaryTaxonomySwitch": "Y"
}
},
"HealthcareProviderTaxonomyGroups": null
}
}