Provider Demographics
NPI:1508141748
Name:SMITH, KYLA MARIE (PT, DPT)
Entity Type:Individual
Prefix:
First Name:KYLA
Middle Name:MARIE
Last Name:SMITH
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:218 S MAIN ST
Mailing Address - Street 2:APT. 3
Mailing Address - City:NICHOLS
Mailing Address - State:NY
Mailing Address - Zip Code:13812-2601
Mailing Address - Country:US
Mailing Address - Phone:607-215-9489
Mailing Address - Fax:
Practice Address - Street 1:205 E 1ST ST
Practice Address - Street 2:
Practice Address - City:CORNING
Practice Address - State:NY
Practice Address - Zip Code:14830-2809
Practice Address - Country:US
Practice Address - Phone:607-654-2400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-10-19
Last Update Date:2011-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY034181-1225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist