Provider Demographics
NPI:1194159889
Name:KWON, ANGIE LEE
Entity type:Individual
Prefix:
First Name:ANGIE
Middle Name:LEE
Last Name:KWON
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 1:1045 JAMES ST
Mailing Address - Street 2:
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13203-2730
Mailing Address - Country:US
Mailing Address - Phone:315-425-1004
Mailing Address - Fax:315-422-4855
Practice Address - Street 1:1870 WINTON RD S
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14618-3960
Practice Address - Country:US
Practice Address - Phone:585-697-1557
Practice Address - Fax:315-697-5692
Is Sole Proprietor?:No
Enumeration Date:2013-08-29
Last Update Date:2013-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2516964222Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist