Provider Demographics
NPI:1649527268
Name:WAHL, KELLY J (LMT)
Entity type:Individual
Prefix:MS
First Name:KELLY
Middle Name:J
Last Name:WAHL
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3083 WILLIAM STREET
Mailing Address - Street 2:SUITE 4
Mailing Address - City:CHEEKTOWAGA
Mailing Address - State:NY
Mailing Address - Zip Code:14227
Mailing Address - Country:US
Mailing Address - Phone:716-544-0753
Mailing Address - Fax:716-783-8727
Practice Address - Street 1:3083 WILLIAM ST
Practice Address - Street 2:SUITE 4
Practice Address - City:CHEEKTOWAGA
Practice Address - State:NY
Practice Address - Zip Code:14227-1933
Practice Address - Country:US
Practice Address - Phone:716-544-0753
Practice Address - Fax:716-783-8727
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-14
Last Update Date:2012-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY020632-1225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist