1154790178 NPI number — EMILY ELIZABETH SRNKA PT, DPT

Table of content: EMILY ELIZABETH SRNKA PT, DPT (NPI 1154790178)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1154790178 NPI number — EMILY ELIZABETH SRNKA PT, DPT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SRNKA
Provider First Name:
EMILY
Provider Middle Name:
ELIZABETH
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PT, DPT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
LOCKHART
Provider Other First Name:
EMILY
Provider Other Middle Name:
ELIZABETH
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
PT, DPT
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1154790178
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/09/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
21756 STATE ROAD 54
Provider Second Line Business Mailing Address:
STE 102
Provider Business Mailing Address City Name:
LUTZ
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33549-2905
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
847-295-1241
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
775 N BANK LN
Provider Second Line Business Practice Location Address:
SUITE 104
Provider Business Practice Location Address City Name:
LAKE FOREST
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60045-1890
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
847-295-1241
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/21/2015

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  13022 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 225100000X , with the licence number: 070021764 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 225100000X , with the licence number: PT34544 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: PT34544 . This is a "PT LICENSE" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".