Provider Demographics
NPI:1427428283
Name:MALSTROM, KELLY KATHRYN (DPT)
Entity type:Individual
Prefix:MS
First Name:KELLY
Middle Name:KATHRYN
Last Name:MALSTROM
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 1:4498 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:AMHERST
Mailing Address - State:NY
Mailing Address - Zip Code:14226-3826
Mailing Address - Country:US
Mailing Address - Phone:716-839-1550
Mailing Address - Fax:716-839-1696
Practice Address - Street 1:4498 MAIN ST
Practice Address - Street 2:
Practice Address - City:AMHERST
Practice Address - State:NY
Practice Address - Zip Code:14226-3826
Practice Address - Country:US
Practice Address - Phone:716-839-1550
Practice Address - Fax:716-839-1696
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-05
Last Update Date:2015-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY039470-1225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist