Provider Demographics
NPI:1518188390
Name:KIRTIO, JEAN M (PHYSICAL THER ASST)
Entity Type:Individual
Prefix:MRS
First Name:JEAN
Middle Name:M
Last Name:KIRTIO
Suffix:
Gender:F
Credentials:PHYSICAL THER ASST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:99 W CORBETT RD
Mailing Address - Street 2:
Mailing Address - City:MONTGOMERY
Mailing Address - State:NY
Mailing Address - Zip Code:12549-1923
Mailing Address - Country:US
Mailing Address - Phone:845-336-7235
Mailing Address - Fax:
Practice Address - Street 1:250 TUYTENBRIDGE RD
Practice Address - Street 2:
Practice Address - City:LAKE KATRINE
Practice Address - State:NY
Practice Address - Zip Code:12449-5429
Practice Address - Country:US
Practice Address - Phone:845-336-7235
Practice Address - Fax:845-336-4726
Is Sole Proprietor?:No
Enumeration Date:2007-05-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY003406-1225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00473001Medicaid
NYW03821Medicare ID - Type Unspecified
NY00473001Medicaid