Provider Demographics
NPI:1285854570
Name:WOOD, KELLIE ANN (PTA)
Entity Type:Individual
Prefix:
First Name:KELLIE
Middle Name:ANN
Last Name:WOOD
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:607 E MOLLOY RD
Mailing Address - Street 2:
Mailing Address - City:MATTYDALE
Mailing Address - State:NY
Mailing Address - Zip Code:13211-1645
Mailing Address - Country:US
Mailing Address - Phone:315-455-8463
Mailing Address - Fax:
Practice Address - Street 1:242 PORT WATSON ST
Practice Address - Street 2:FADDEN & ASSOCIATES PHYSICAL THERAPY PLLC
Practice Address - City:CORTLAND
Practice Address - State:NY
Practice Address - Zip Code:13045
Practice Address - Country:US
Practice Address - Phone:607-758-7212
Practice Address - Fax:607-758-3416
Is Sole Proprietor?:No
Enumeration Date:2007-04-27
Last Update Date:2011-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY002025-1225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant