Provider Demographics
NPI:1023486099
Name:KRESTAN, GLORIA FUTHEY (LAT, ATC)
Entity type:Individual
Prefix:
First Name:GLORIA
Middle Name:FUTHEY
Last Name:KRESTAN
Suffix:
Gender:F
Credentials:LAT, ATC
Other - Prefix:
Other - First Name:GLORIA
Other - Middle Name:LOUISE
Other - Last Name:FUTHEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2729 MERRILEE DR APT 535
Mailing Address - Street 2:
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22031-4445
Mailing Address - Country:US
Mailing Address - Phone:803-415-4262
Mailing Address - Fax:
Practice Address - Street 1:4117 STADIUM DRIVE
Practice Address - Street 2:
Practice Address - City:COLLEGE PARK
Practice Address - State:MD
Practice Address - Zip Code:20742-4765
Practice Address - Country:US
Practice Address - Phone:240-825-5159
Practice Address - Fax:877-863-2802
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-09
Last Update Date:2021-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
2255A2300X, 390200000X
MDA00013672255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program