Provider Demographics
NPI:1669140315
Name:MACE, KAELI A (PT)
Entity type:Individual
Prefix:
First Name:KAELI
Middle Name:A
Last Name:MACE
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 1:289 HURRICANE LN STE 102
Mailing Address - Street 2:
Mailing Address - City:WILLISTON
Mailing Address - State:VT
Mailing Address - Zip Code:05495-2092
Mailing Address - Country:US
Mailing Address - Phone:802-655-7575
Mailing Address - Fax:
Practice Address - Street 1:289 HURRICANE LN STE 102
Practice Address - Street 2:
Practice Address - City:WILLISTON
Practice Address - State:VT
Practice Address - Zip Code:05495-2092
Practice Address - Country:US
Practice Address - Phone:802-655-7575
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-30
Last Update Date:2021-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT040.0134316225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT040.0134316OtherSTATE LICENSE