Provider Demographics
NPI:1033723226
Name:BOULERIS, KAELEE (ATC)
Entity Type:Individual
Prefix:
First Name:KAELEE
Middle Name:
Last Name:BOULERIS
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:203 COUNTY ROUTE 70
Mailing Address - Street 2:
Mailing Address - City:STILLWATER
Mailing Address - State:NY
Mailing Address - Zip Code:12170-2000
Mailing Address - Country:US
Mailing Address - Phone:518-779-5540
Mailing Address - Fax:
Practice Address - Street 1:203 COUNTY ROUTE 70
Practice Address - Street 2:
Practice Address - City:STILLWATER
Practice Address - State:NY
Practice Address - Zip Code:12170-2000
Practice Address - Country:US
Practice Address - Phone:518-779-5540
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-03
Last Update Date:2021-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT104729146N00000X
2255A2300X, 390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No146N00000XEmergency Medical Service ProvidersEmergency Medical Technician, Basic
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer