Healthcare Provider Details

I. General information

NPI: 1033652367
Provider Name (Legal Business Name): KEVIN WALTHER PT, DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/18/2016
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3506 THOMAS DR
LAKEVILLE NY
14480-9730
US

IV. Provider business mailing address

5176 CANADICE LAKE RD
HEMLOCK NY
14466
US

V. Phone/Fax

Practice location:
  • Phone: 585-346-0060
  • Fax: 585-346-0108
Mailing address:
  • Phone: 585-278-6458
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number040876
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: