Provider Demographics
NPI:1104251271
Name:MAINE, KELLY (DPT)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:MAINE
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3401 TONAWANDA CREEK RD
Mailing Address - Street 2:
Mailing Address - City:AMHERST
Mailing Address - State:NY
Mailing Address - Zip Code:14228-1506
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2111 W 8TH ST
Practice Address - Street 2:
Practice Address - City:ERIE
Practice Address - State:PA
Practice Address - Zip Code:16505-4707
Practice Address - Country:US
Practice Address - Phone:814-456-5151
Practice Address - Fax:814-878-2911
Is Sole Proprietor?:No
Enumeration Date:2013-09-09
Last Update Date:2013-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPT022904225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist