Provider Demographics
NPI:1821115486
Name:BUCCIERI, KATHLEEN (PT)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:
Last Name:BUCCIERI
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 1:9 BROOKSIDE DR
Mailing Address - Street 2:
Mailing Address - City:FAIRPORT
Mailing Address - State:NY
Mailing Address - Zip Code:14450-2229
Mailing Address - Country:US
Mailing Address - Phone:585-377-2605
Mailing Address - Fax:
Practice Address - Street 1:100 METRO PARK
Practice Address - Street 2:SUITE 105
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14623-2610
Practice Address - Country:US
Practice Address - Phone:585-427-7610
Practice Address - Fax:585-427-7410
Is Sole Proprietor?:No
Enumeration Date:2007-03-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY007694-1225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
RC62007694OtherRICPA
7063209OtherAETNA
7702287OtherMVP