Provider Demographics
NPI:1518123587
Name:KROLL, KEITH JAMES (PTA)
Entity Type:Individual
Prefix:
First Name:KEITH
Middle Name:JAMES
Last Name:KROLL
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:475 E MAIN ST
Mailing Address - Street 2:SUITE 103-105
Mailing Address - City:PATCHOGUE
Mailing Address - State:NY
Mailing Address - Zip Code:11772-3121
Mailing Address - Country:US
Mailing Address - Phone:631-289-0044
Mailing Address - Fax:631-447-6126
Practice Address - Street 1:2412 150TH ST
Practice Address - Street 2:
Practice Address - City:WHITESTONE
Practice Address - State:NY
Practice Address - Zip Code:11357-3634
Practice Address - Country:US
Practice Address - Phone:718-661-4040
Practice Address - Fax:718-888-9418
Is Sole Proprietor?:No
Enumeration Date:2008-07-30
Last Update Date:2008-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYTE007735225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant