Provider Demographics
NPI:1093214165
Name:WALLACH, KELSEY ELAINE (DPT)
Entity type:Individual
Prefix:
First Name:KELSEY
Middle Name:ELAINE
Last Name:WALLACH
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:KELSEY
Other - Middle Name:
Other - Last Name:HELLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DPT
Mailing Address - Street 1:200 FRONT ST
Mailing Address - Street 2:SUITE D
Mailing Address - City:VESTAL
Mailing Address - State:NY
Mailing Address - Zip Code:13850
Mailing Address - Country:US
Mailing Address - Phone:607-754-1776
Mailing Address - Fax:607-748-5465
Practice Address - Street 1:200 FRONT ST
Practice Address - Street 2:SUITE D
Practice Address - City:VESTAL
Practice Address - State:NY
Practice Address - Zip Code:13850
Practice Address - Country:US
Practice Address - Phone:607-754-1776
Practice Address - Fax:607-748-5465
Is Sole Proprietor?:No
Enumeration Date:2018-02-05
Last Update Date:2024-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY042766225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist