Provider Demographics
NPI:1083313068
Name:KLACZKO, AMANDA (DPT)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:KLACZKO
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 1:1 RIVER ST UNIT 201
Mailing Address - Street 2:
Mailing Address - City:MILTON
Mailing Address - State:VT
Mailing Address - Zip Code:05468-3867
Mailing Address - Country:US
Mailing Address - Phone:315-882-8547
Mailing Address - Fax:
Practice Address - Street 1:75 EASTWOOD DR
Practice Address - Street 2:
Practice Address - City:SOUTH BURLINGTON
Practice Address - State:VT
Practice Address - Zip Code:05403-4402
Practice Address - Country:US
Practice Address - Phone:802-860-0209
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-28
Last Update Date:2023-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT040.0134306225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist