Healthcare Provider Details

I. General information

NPI: 1336074087
Provider Name (Legal Business Name): ADDISON JO HERZBERG PT, DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/15/2026
Last Update Date: 06/15/2026
Certification Date: 06/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19931 W KELLOGG DR UNIT A
GODDARD KS
67052-8864
US

IV. Provider business mailing address

19931 W KELLOGG DR UNIT A
GODDARD KS
67052-8864
US

V. Phone/Fax

Practice location:
  • Phone: 316-800-6227
  • Fax:
Mailing address:
  • Phone: 316-800-6227
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number11-08156
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: