Provider Demographics
NPI:1114597879
Name:KANEFSKY, ILENE SHARON (PTA)
Entity Type:Individual
Prefix:
First Name:ILENE
Middle Name:SHARON
Last Name:KANEFSKY
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8417 E CORINTHIAN DR
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85715-5445
Mailing Address - Country:US
Mailing Address - Phone:561-373-5400
Mailing Address - Fax:
Practice Address - Street 1:2550 N CRAYCROFT RD
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85712
Practice Address - Country:US
Practice Address - Phone:520-730-8752
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-25
Last Update Date:2021-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ010126225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant