Provider Demographics
NPI:1962984898
Name:KALLASY, TYLER J (DPT)
Entity type:Individual
Prefix:
First Name:TYLER
Middle Name:J
Last Name:KALLASY
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:409 SUNLIT TER
Mailing Address - Street 2:
Mailing Address - City:UTICA
Mailing Address - State:NY
Mailing Address - Zip Code:13502-2407
Mailing Address - Country:US
Mailing Address - Phone:315-749-6853
Mailing Address - Fax:209-576-0913
Practice Address - Street 1:5720 LAMAR ST UNIT 5
Practice Address - Street 2:
Practice Address - City:ARVADA
Practice Address - State:CO
Practice Address - Zip Code:80002-2612
Practice Address - Country:US
Practice Address - Phone:315-749-6853
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-06
Last Update Date:2023-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA296669225100000X
MA24723225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty