Provider Demographics
NPI:1285477224
Name:AMORMINO, MAX KIEFFER (PT, DPT)
Entity type:Individual
Prefix:
First Name:MAX
Middle Name:KIEFFER
Last Name:AMORMINO
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3900 WHITE SETTLEMENT RD APT 102
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76107-7822
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3975 OLD REDWOOD HWY
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95403-1719
Practice Address - Country:US
Practice Address - Phone:707-566-5557
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-17
Last Update Date:2024-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA306144225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist