Provider Demographics
NPI:1760538631
Name:SACK, KELLY J (MPT)
Entity Type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:J
Last Name:SACK
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:116 BUCKNELL RD
Mailing Address - Street 2:
Mailing Address - City:WEST SAYVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:11796-1005
Mailing Address - Country:US
Mailing Address - Phone:631-258-6111
Mailing Address - Fax:
Practice Address - Street 1:45 CROSSWAY E
Practice Address - Street 2:
Practice Address - City:BOHEMIA
Practice Address - State:NY
Practice Address - Zip Code:11716-1204
Practice Address - Country:US
Practice Address - Phone:631-218-4949
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0194782251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics