Provider Demographics
NPI:1235663519
Name:KOTKIEWICZ, JEAN MARIE (PT, DPT, CLT, WCC)
Entity Type:Individual
Prefix:
First Name:JEAN
Middle Name:MARIE
Last Name:KOTKIEWICZ
Suffix:
Gender:F
Credentials:PT, DPT, CLT, WCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3 PETERS PATH
Mailing Address - Street 2:
Mailing Address - City:EAST SETAUKET
Mailing Address - State:NY
Mailing Address - Zip Code:11733-3719
Mailing Address - Country:US
Mailing Address - Phone:631-838-8841
Mailing Address - Fax:
Practice Address - Street 1:3 PETERS PATH
Practice Address - Street 2:
Practice Address - City:EAST SETAUKET
Practice Address - State:NY
Practice Address - Zip Code:11733-3719
Practice Address - Country:US
Practice Address - Phone:631-838-8841
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-13
Last Update Date:2017-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY027785225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist