Provider Demographics
NPI:1346824836
Name:KLAKOTSKIY, MIKHAIL (DPT)
Entity Type:Individual
Prefix:DR
First Name:MIKHAIL
Middle Name:
Last Name:KLAKOTSKIY
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:420 MAIN ST APT 62
Mailing Address - Street 2:
Mailing Address - City:AGAWAM
Mailing Address - State:MA
Mailing Address - Zip Code:01001-1844
Mailing Address - Country:US
Mailing Address - Phone:413-426-2555
Mailing Address - Fax:
Practice Address - Street 1:25 LORRAINE ST
Practice Address - Street 2:
Practice Address - City:HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06105-2242
Practice Address - Country:US
Practice Address - Phone:860-233-8241
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-10
Last Update Date:2021-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT012324225100000X
MA25470225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist