Provider Demographics
NPI:1932181542
Name:KMIECZAK, KEITH (MSPT)
Entity Type:Individual
Prefix:
First Name:KEITH
Middle Name:
Last Name:KMIECZAK
Suffix:
Gender:M
Credentials:MSPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:297 ORCHARD VIEW DR
Mailing Address - Street 2:
Mailing Address - City:LEOLA
Mailing Address - State:PA
Mailing Address - Zip Code:17540-1632
Mailing Address - Country:US
Mailing Address - Phone:717-283-6797
Mailing Address - Fax:
Practice Address - Street 1:136 LAKE ST
Practice Address - Street 2:SUITE E
Practice Address - City:EPHRATA
Practice Address - State:PA
Practice Address - Zip Code:17522
Practice Address - Country:US
Practice Address - Phone:717-466-5880
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-18
Last Update Date:2022-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPT013342L225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA2053032000OtherINDEPENDENCE BLUE SHIELD
PA50017328OtherCAPITAL BLUE CROSS
PA2719587OtherAETNA
PA814494OtherFIRST PRIORITY
PA1360739OtherBLUE SHIELD