Provider Demographics
NPI:1194811125
Name:ZAWACKI, KELLY M (PT)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:M
Last Name:ZAWACKI
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:M
Other - Last Name:COLEMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:510 TOWNE DR
Mailing Address - Street 2:STE 100
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:13066-1331
Mailing Address - Country:US
Mailing Address - Phone:315-637-4747
Mailing Address - Fax:315-637-6711
Practice Address - Street 1:510 TOWNE DR
Practice Address - Street 2:STE 100
Practice Address - City:FAYETTEVILLE
Practice Address - State:NY
Practice Address - Zip Code:13066-1331
Practice Address - Country:US
Practice Address - Phone:315-637-4747
Practice Address - Fax:315-637-6711
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-05
Last Update Date:2010-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY014387225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY435176OtherMVP
NY435176OtherMVP