Provider Demographics
NPI:1154310258
Name:KOUTSOURADES, KAREN JUDITH (PT)
Entity Type:Individual
Prefix:
First Name:KAREN
Middle Name:JUDITH
Last Name:KOUTSOURADES
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:215 WASHINGTON AVENUE EXT
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:NY
Mailing Address - Zip Code:12205-5534
Mailing Address - Country:US
Mailing Address - Phone:518-452-0914
Mailing Address - Fax:518-452-5953
Practice Address - Street 1:215 WASHINGTON AVENUE EXT
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:NY
Practice Address - Zip Code:12205-5534
Practice Address - Country:US
Practice Address - Phone:518-452-0914
Practice Address - Fax:518-452-5953
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY019759225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02549686Medicaid
NY02549686Medicaid