Provider Demographics
NPI:1750320677
Name:KNELSEN, CLIFFORD P (PT)
Entity Type:Individual
Prefix:MR
First Name:CLIFFORD
Middle Name:P
Last Name:KNELSEN
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 1:328 WARNER DR
Mailing Address - Street 2:STE 8
Mailing Address - City:LEWISTON
Mailing Address - State:ID
Mailing Address - Zip Code:83501-4441
Mailing Address - Country:US
Mailing Address - Phone:208-746-7573
Mailing Address - Fax:208-746-4519
Practice Address - Street 1:328 WARNER DR
Practice Address - Street 2:STE 8
Practice Address - City:LEWISTON
Practice Address - State:ID
Practice Address - Zip Code:83501-4441
Practice Address - Country:US
Practice Address - Phone:208-746-7573
Practice Address - Fax:208-746-4519
Is Sole Proprietor?:No
Enumeration Date:2006-06-06
Last Update Date:2010-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPT1687225100000X
WAPT00008736225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID806463200Medicaid
ID806463200Medicaid