Healthcare Provider Details

I. General information

NPI: 1831782820
Provider Name (Legal Business Name): COURTNEY KLUSEK
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/19/2021
Last Update Date: 03/01/2023
Certification Date: 03/01/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14557 W INDIAN SCHOOL RD
GOODYEAR AZ
85395-9243
US

IV. Provider business mailing address

12813 W ALVARADO RD
AVONDALE AZ
85392-7053
US

V. Phone/Fax

Practice location:
  • Phone: 623-242-6908
  • Fax:
Mailing address:
  • Phone: 602-639-1572
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251P0200X
TaxonomyPediatric Physical Therapist
License Number31618
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: