Healthcare Provider Details

I. General information

NPI: 1235663519
Provider Name (Legal Business Name): JEAN MARIE KOTKIEWICZ PT, DPT, CLT, WCC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/13/2017
Last Update Date: 04/13/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3 PETERS PATH
EAST SETAUKET NY
11733-3719
US

IV. Provider business mailing address

3 PETERS PATH
EAST SETAUKET NY
11733-3719
US

V. Phone/Fax

Practice location:
  • Phone: 631-838-8841
  • Fax:
Mailing address:
  • Phone: 631-838-8841
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number027785
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: