Provider Demographics
NPI:1699275396
Name:SEROKA, KRISTEN MARIE (PT)
Entity type:Individual
Prefix:
First Name:KRISTEN
Middle Name:MARIE
Last Name:SEROKA
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20329 N 59TH AVE STE A2
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85308-6854
Mailing Address - Country:US
Mailing Address - Phone:623-215-4161
Mailing Address - Fax:623-201-8589
Practice Address - Street 1:20329 N 59TH AVE STE A2
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85308-6854
Practice Address - Country:US
Practice Address - Phone:623-215-4161
Practice Address - Fax:623-201-8589
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-19
Last Update Date:2019-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ13375225100000X
OHPT016495225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist