Provider Demographics
NPI:1619535259
Name:ESTRADA, KETZIEL (DPT)
Entity Type:Individual
Prefix:
First Name:KETZIEL
Middle Name:
Last Name:ESTRADA
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1226 E CUMBERLAND AVE UNIT 120
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33602-4212
Mailing Address - Country:US
Mailing Address - Phone:787-608-3490
Mailing Address - Fax:
Practice Address - Street 1:2202 W OAK AVE
Practice Address - Street 2:
Practice Address - City:PLANT CITY
Practice Address - State:FL
Practice Address - Zip Code:33563-7222
Practice Address - Country:US
Practice Address - Phone:813-754-3761
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-30
Last Update Date:2019-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT33977225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist