Provider Demographics
NPI:1760812473
Name:POLLY, KATHLEEN BRONCHETTI (PT, DPT)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:BRONCHETTI
Last Name:POLLY
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:KATHLEEN
Other - Middle Name:
Other - Last Name:BRONCHETTI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:114 WATCHTOWER LN
Mailing Address - Street 2:
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13219-1326
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:750 E ADAMS ST
Practice Address - Street 2:SUITE 2104 UH
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13210-2342
Practice Address - Country:US
Practice Address - Phone:315-464-6543
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-11-15
Last Update Date:2015-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY036608225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist