Provider Demographics
NPI:1487193280
Name:MASTELLAR, KASEY (PT, DPT)
Entity Type:Individual
Prefix:
First Name:KASEY
Middle Name:
Last Name:MASTELLAR
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:KASEY
Other - Middle Name:
Other - Last Name:WILCOX
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:19 APPLE ORCHARD RD
Mailing Address - Street 2:
Mailing Address - City:BENTON
Mailing Address - State:PA
Mailing Address - Zip Code:17814-8144
Mailing Address - Country:US
Mailing Address - Phone:570-854-8772
Mailing Address - Fax:
Practice Address - Street 1:918 MAIN STREET
Practice Address - Street 2:SUITE 1
Practice Address - City:LAPORTE
Practice Address - State:PA
Practice Address - Zip Code:18626-0100
Practice Address - Country:US
Practice Address - Phone:570-946-7700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-02-14
Last Update Date:2017-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPT025809225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist