Provider Demographics
NPI:1871781526
Name:FEREZA, KIMBERLY
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:FEREZA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:950 S CENTRAL AVE STE 6
Mailing Address - Street 2:
Mailing Address - City:CANONSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:15317-1489
Mailing Address - Country:US
Mailing Address - Phone:724-884-6936
Mailing Address - Fax:
Practice Address - Street 1:950 S CENTRAL AVE STE 6
Practice Address - Street 2:
Practice Address - City:CANONSBURG
Practice Address - State:PA
Practice Address - Zip Code:15317-1489
Practice Address - Country:US
Practice Address - Phone:724-844-6936
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-09
Last Update Date:2020-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPT008670L225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1871781526Medicaid