=====================================================
General NPI Number Information
=====================================================
NPI Number | 1790368447
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KIRBY AHLSTROM PTA
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/30/2021
-----------------------------------------------------
Last Update Date | 12/10/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 310 SUNNYVIEW LN
-----------------------------------------------------
City | KALISPELL
-----------------------------------------------------
State | MT
-----------------------------------------------------
Zip | 59901-3129
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 406-752-5111
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 335 4TH ST E
-----------------------------------------------------
City | COLUMBIA FALLS
-----------------------------------------------------
State | MT
-----------------------------------------------------
Zip | 59912-3534
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 443-871-1545
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225700000X
-----------------------------------------------------
Taxonomy Name | Massage Therapist
-----------------------------------------------------
License Number | MASS-15880
-----------------------------------------------------
License Number State | MT
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 225200000X
-----------------------------------------------------
Taxonomy Name | Physical Therapy Assistant
-----------------------------------------------------
License Number | PTP-PTA-LIC-19447
-----------------------------------------------------
License Number State | MT
-----------------------------------------------------