Provider Demographics
NPI:1720394786
Name:SERENA, VELVET JEAN (PTA)
Entity Type:Individual
Prefix:
First Name:VELVET
Middle Name:JEAN
Last Name:SERENA
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:PO BOX 6059
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58108-6059
Mailing Address - Country:US
Mailing Address - Phone:188-887-3422
Mailing Address - Fax:188-854-3228
Practice Address - Street 1:7540 N 19TH AVE STE 200
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85021-7967
Practice Address - Country:US
Practice Address - Phone:188-887-3422
Practice Address - Fax:188-854-3228
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-27
Last Update Date:2010-08-27
Deactivation Date:
Deactivation Code:
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Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant