Provider Demographics
NPI:1679751531
Name:WASKEWICZ, KATHLEEN MARIE (PT)
Entity Type:Individual
Prefix:MS
First Name:KATHLEEN
Middle Name:MARIE
Last Name:WASKEWICZ
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24 BEACH AVE
Mailing Address - Street 2:
Mailing Address - City:PORT JEFFERSON STATION
Mailing Address - State:NY
Mailing Address - Zip Code:11776-2102
Mailing Address - Country:US
Mailing Address - Phone:631-474-4578
Mailing Address - Fax:
Practice Address - Street 1:24 BEACH AVE
Practice Address - Street 2:
Practice Address - City:PORT JEFFERSON STATION
Practice Address - State:NY
Practice Address - Zip Code:11776-2102
Practice Address - Country:US
Practice Address - Phone:631-474-4578
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-02-03
Last Update Date:2008-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY8633225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYQ15741OtherMEDICARE PART B PROGRAM