Healthcare Provider Details

I. General information

NPI: 1164455531
Provider Name (Legal Business Name): KILLEEN THERAPY SERVICES, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/09/2006
Last Update Date: 02/05/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19047 N 76TH AVE
GLENDALE AZ
85308-8304
US

IV. Provider business mailing address

19047 N 76TH AVE
GLENDALE AZ
85308-8304
US

V. Phone/Fax

Practice location:
  • Phone: 623-561-0499
  • Fax:
Mailing address:
  • Phone: 623-341-0016
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License Number
License Number State

VIII. Authorized Official

Name: DIANE M KILLEEN
Title or Position: PRESIDENT
Credential:
Phone: 623-341-0016