Healthcare Provider Details

I. General information

NPI: 1043661267
Provider Name (Legal Business Name): BRANDON M KUDASIK PT, DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/29/2016
Last Update Date: 06/29/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

991 ROUTE 19N SUITE E WATERFORD PHYSICAL THERAPY INC.
WATERFORD PA
16441-9739
US

IV. Provider business mailing address

991 ROUTE 19N SUITE E WATERFORD PHYSICAL THERAPY INC.
WATERFORD PA
16441-9739
US

V. Phone/Fax

Practice location:
  • Phone: 814-796-3400
  • Fax: 814-796-8533
Mailing address:
  • Phone: 814-796-3400
  • Fax: 814-796-8533

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT025206
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: