Healthcare Provider Details

I. General information

NPI: 1487876512
Provider Name (Legal Business Name): TODD J KOTYK P.T.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/02/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

153 EAST PIKE ST.
CANONSBURG PA
15317-1765
US

IV. Provider business mailing address

153 E PIKE ST
CANONSBURG PA
15317-1765
US

V. Phone/Fax

Practice location:
  • Phone: 724-745-5646
  • Fax: 724-745-6062
Mailing address:
  • Phone: 724-745-5646
  • Fax: 724-745-6062

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT-009765-L
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number2484
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: