Basic Information
| Provider Information | |||||||||
| NPI: | 1932585320 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CLESEN | ||||||||
| FirstName: | KENNETH | ||||||||
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| NameSuffix: | JR. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2571 CEDAR CYPRESS CT | ||||||||
| Address2: | |||||||||
| City: | TAMPA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 336183341 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3322235466 | ||||||||
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| Practice Location | |||||||||
| Address1: | 13020 N TELECOM PKWY | ||||||||
| Address2: | |||||||||
| City: | TEMPLE TERRACE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 336370925 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8139789700 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/07/2015 | ||||||||
| LastUpdateDate: | 01/24/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/24/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | PT 30662 | FL | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 2251X0800X | PT30662 | FL | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Orthopedic |
No ID Information.