Provider Demographics
NPI:1588044853
Name:GANIKO, KELLI (PT, DPT, MOT, OTR/L)
Entity Type:Individual
Prefix:
First Name:KELLI
Middle Name:
Last Name:GANIKO
Suffix:
Gender:F
Credentials:PT, DPT, MOT, OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6 CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:WAILUKU
Mailing Address - State:HI
Mailing Address - Zip Code:96793-1703
Mailing Address - Country:US
Mailing Address - Phone:808-244-5541
Mailing Address - Fax:808-242-8485
Practice Address - Street 1:6 CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:WAILUKU
Practice Address - State:HI
Practice Address - Zip Code:96793-1703
Practice Address - Country:US
Practice Address - Phone:808-244-5541
Practice Address - Fax:808-242-8485
Is Sole Proprietor?:No
Enumeration Date:2015-06-02
Last Update Date:2017-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIPT-4063225100000X
HIOT1467225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist