Provider Demographics
NPI:1821117904
Name:SEAGO, KOREN E (MS,PT)
Entity Type:Individual
Prefix:
First Name:KOREN
Middle Name:E
Last Name:SEAGO
Suffix:
Gender:F
Credentials:MS,PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14630 E WALNUT RUN
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46814-8907
Mailing Address - Country:US
Mailing Address - Phone:765-506-0745
Mailing Address - Fax:
Practice Address - Street 1:3840 NEW VISION DR
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46845-1708
Practice Address - Country:US
Practice Address - Phone:260-483-2422
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-28
Last Update Date:2015-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN05009222A225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN05009222AOtherPHYSICAL THERAPY LICENSE