Provider Demographics
NPI:1588022982
Name:NOTLEY-KIM, AMANDA (PT)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:NOTLEY-KIM
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:
Other - Last Name:NOTLEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 493
Mailing Address - Street 2:
Mailing Address - City:VALLEY COTTAGE
Mailing Address - State:NY
Mailing Address - Zip Code:10989-0493
Mailing Address - Country:US
Mailing Address - Phone:845-675-8444
Mailing Address - Fax:845-675-0333
Practice Address - Street 1:15 LAKE RIDGE PLZ
Practice Address - Street 2:
Practice Address - City:VALLEY COTTAGE
Practice Address - State:NY
Practice Address - Zip Code:10989-1925
Practice Address - Country:US
Practice Address - Phone:845-675-8444
Practice Address - Fax:845-675-0333
Is Sole Proprietor?:No
Enumeration Date:2016-02-01
Last Update Date:2023-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY039663225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYQ4WFH1Medicare PIN