Provider Demographics
NPI:1679089593
Name:PEREK, KRISTEN (DPT)
Entity type:Individual
Prefix:
First Name:KRISTEN
Middle Name:
Last Name:PEREK
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6037 HARRIS PKWY
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76132-4103
Mailing Address - Country:US
Mailing Address - Phone:817-370-9891
Mailing Address - Fax:
Practice Address - Street 1:6037 HARRIS PKWY
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76132-4103
Practice Address - Country:US
Practice Address - Phone:817-370-9891
Practice Address - Fax:817-370-9894
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-15
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1299129225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
1299129OtherPT LICENSE