Provider Demographics
NPI:1780092064
Name:KAGARISE, ADAM (DPT)
Entity type:Individual
Prefix:MR
First Name:ADAM
Middle Name:
Last Name:KAGARISE
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 1:8073 WASHINGTON VILLAGE DRIVE
Mailing Address - Street 2:SUITE 110
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45458-1847
Mailing Address - Country:US
Mailing Address - Phone:937-813-8052
Mailing Address - Fax:937-813-8056
Practice Address - Street 1:755 BOARDMAN CANFIELD RD
Practice Address - Street 2:BUILDING P UNIT 1
Practice Address - City:BOARDMAN
Practice Address - State:OH
Practice Address - Zip Code:44512-4300
Practice Address - Country:US
Practice Address - Phone:330-726-7404
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-07-30
Last Update Date:2016-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH014974225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist