Provider Demographics
NPI:1841543105
Name:REDFERN, EMILENE (PT)
Entity type:Individual
Prefix:
First Name:EMILENE
Middle Name:
Last Name:REDFERN
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:EMILENE
Other - Middle Name:
Other - Last Name:CLARK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:2108 E THOMAS RD STE 130
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85016-0008
Mailing Address - Country:US
Mailing Address - Phone:602-933-3124
Mailing Address - Fax:
Practice Address - Street 1:3530 S VAL VISTA DR STE B205
Practice Address - Street 2:
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85297-7318
Practice Address - Country:US
Practice Address - Phone:602-933-7528
Practice Address - Fax:602-933-4296
Is Sole Proprietor?:No
Enumeration Date:2012-10-23
Last Update Date:2024-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ9961225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ901851Medicaid