Basic Information
| Provider Information | |||||||||
| NPI: | 1861499642 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KLAWONN | ||||||||
| FirstName: | AMISHA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | PT, DPT, OCS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10324 N. 62ND DRIVE | ||||||||
| Address2: | |||||||||
| City: | GLENDALE | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 85302 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6027787609 | ||||||||
| FaxNumber: | 6026670174 | ||||||||
| Practice Location | |||||||||
| Address1: | 2122 E. HIGHLAND | ||||||||
| Address2: | #200 | ||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 85016 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6239790066 | ||||||||
| FaxNumber: | 6239790052 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/07/2005 | ||||||||
| LastUpdateDate: | 02/04/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 5353 | AZ | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 575524 | 05 | AZ | MEDICAID |