Provider Demographics
NPI:1184670598
Name:KISICKI, DAVID S (PT)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:S
Last Name:KISICKI
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6520 W HAPPY VALLEY RD
Mailing Address - Street 2:STE B 109
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85310-2615
Mailing Address - Country:US
Mailing Address - Phone:623-561-1300
Mailing Address - Fax:623-561-0036
Practice Address - Street 1:6520 W HAPPY VALLEY RD
Practice Address - Street 2:STE B 109
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85310-2615
Practice Address - Country:US
Practice Address - Phone:623-561-1300
Practice Address - Fax:623-561-0036
Is Sole Proprietor?:No
Enumeration Date:2006-05-26
Last Update Date:2010-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ5621225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ4920680001Medicare NSC
AZ107819Medicare ID - Type Unspecified