Provider Demographics
NPI:1922538313
Name:KOVALESKI, ZACHARY (PTA)
Entity Type:Individual
Prefix:MR
First Name:ZACHARY
Middle Name:
Last Name:KOVALESKI
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:417 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:RICHMONDALE
Mailing Address - State:PA
Mailing Address - Zip Code:18421-9604
Mailing Address - Country:US
Mailing Address - Phone:570-614-3152
Mailing Address - Fax:
Practice Address - Street 1:37 WOODLANDS DR
Practice Address - Street 2:
Practice Address - City:WAYMART
Practice Address - State:PA
Practice Address - Zip Code:18472-9366
Practice Address - Country:US
Practice Address - Phone:570-488-7130
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-18
Last Update Date:2017-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PATE011182225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant