Provider Demographics
NPI:1861920597
Name:INGVALSON, KENT LESLIE (DPT)
Entity type:Individual
Prefix:
First Name:KENT
Middle Name:LESLIE
Last Name:INGVALSON
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2901 GRAND AVE APT 306
Mailing Address - Street 2:
Mailing Address - City:DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50312-4289
Mailing Address - Country:US
Mailing Address - Phone:563-419-3177
Mailing Address - Fax:
Practice Address - Street 1:450 LAUREL ST STE B
Practice Address - Street 2:
Practice Address - City:DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50314-3045
Practice Address - Country:US
Practice Address - Phone:515-323-6485
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-05-25
Last Update Date:2017-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA087723225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist