Healthcare Provider Details

I. General information

NPI: 1689955130
Provider Name (Legal Business Name): JULIE FELLOWS PT, DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JULIE ROLL

II. Dates (important events)

Enumeration Date: 08/29/2011
Last Update Date: 01/31/2022
Certification Date: 01/31/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

462 GRIDER STREET
BUFFALO NY
14215
US

IV. Provider business mailing address

462 GRIDER STREET
BUFFALO NY
14215
US

V. Phone/Fax

Practice location:
  • Phone: 716-898-3895
  • Fax: 813-633-9890
Mailing address:
  • Phone: 716-898-3895
  • Fax: 813-633-9890

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT 26762
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number033967
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: