Provider Demographics
NPI:1326477498
Name:SCANTLEBURY, KELLEN
Entity Type:Individual
Prefix:
First Name:KELLEN
Middle Name:
Last Name:SCANTLEBURY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:611 OLD WILLETS PATH STE 105
Mailing Address - Street 2:
Mailing Address - City:HAUPPAUGE
Mailing Address - State:NY
Mailing Address - Zip Code:11788-4115
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:611 OLD WILLETS PATH STE 105
Practice Address - Street 2:
Practice Address - City:HAUPPAUGE
Practice Address - State:NY
Practice Address - Zip Code:11788-4115
Practice Address - Country:US
Practice Address - Phone:631-232-5350
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-08
Last Update Date:2013-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYP90296225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist