Healthcare Provider Details

I. General information

NPI: 1790540896
Provider Name (Legal Business Name): MAREN SEDERQUIST MES, CPT, CSCS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/19/2024
Last Update Date: 02/19/2024
Certification Date: 02/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1149 KOTENBERG AVE
SAN JOSE CA
95125
US

IV. Provider business mailing address

PO BOX 60538
PALO ALTO CA
94306
US

V. Phone/Fax

Practice location:
  • Phone: 650-336-0087
  • Fax:
Mailing address:
  • Phone: 650-336-0087
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code226300000X
TaxonomyKinesiotherapist
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code174H00000X
TaxonomyHealth Educator
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code224Y00000X
TaxonomyClinical Exercise Physiologist
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: