Provider Demographics
NPI:1710931043
Name:GREENSTREET, KEN L (PT)
Entity Type:Individual
Prefix:MR
First Name:KEN
Middle Name:L
Last Name:GREENSTREET
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:9097 E DESERT COVE AVE
Mailing Address - Street 2:SUITE 110
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85260-6279
Mailing Address - Country:US
Mailing Address - Phone:480-837-2595
Mailing Address - Fax:480-837-2773
Practice Address - Street 1:16838 E PALISADES BLVD
Practice Address - Street 2:BUILDING B
Practice Address - City:FOUNTAIN HILLS
Practice Address - State:AZ
Practice Address - Zip Code:85268-3845
Practice Address - Country:US
Practice Address - Phone:480-837-2595
Practice Address - Fax:480-837-2773
Is Sole Proprietor?:No
Enumeration Date:2006-05-20
Last Update Date:2013-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ5470225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ68844Medicare ID - Type Unspecified