Provider Demographics
NPI:1801322631
Name:KORUTZ, KAITLYN MARIE (BS, PTA)
Entity type:Individual
Prefix:
First Name:KAITLYN
Middle Name:MARIE
Last Name:KORUTZ
Suffix:
Gender:F
Credentials:BS, PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2525 BOLLES HILL RD
Mailing Address - Street 2:
Mailing Address - City:APALACHIN
Mailing Address - State:NY
Mailing Address - Zip Code:13732-3420
Mailing Address - Country:US
Mailing Address - Phone:607-651-8053
Mailing Address - Fax:
Practice Address - Street 1:211 MAIN ST
Practice Address - Street 2:
Practice Address - City:OWEGO
Practice Address - State:NY
Practice Address - Zip Code:13827-1633
Practice Address - Country:US
Practice Address - Phone:607-725-9644
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-05-11
Last Update Date:2017-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PATEI004095225200000X
NY007013225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant