Provider Demographics
NPI:1306504683
Name:WAIKSNORIS, KELLY J (DPT)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:J
Last Name:WAIKSNORIS
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:711 TROY SCHENECTADY RD STE 209
Mailing Address - Street 2:
Mailing Address - City:LATHAM
Mailing Address - State:NY
Mailing Address - Zip Code:12110-2481
Mailing Address - Country:US
Mailing Address - Phone:518-786-1667
Mailing Address - Fax:518-786-1954
Practice Address - Street 1:10 VISTA BLVD
Practice Address - Street 2:
Practice Address - City:SLINGERLANDS
Practice Address - State:NY
Practice Address - Zip Code:12159-2187
Practice Address - Country:US
Practice Address - Phone:518-478-9049
Practice Address - Fax:518-478-0133
Is Sole Proprietor?:No
Enumeration Date:2021-12-03
Last Update Date:2024-05-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NYP113236225100000X
NY048678225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist