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General NPI Number Information
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NPI Number | 1649527268
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Entity Type | Individual
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Provider Name | KELLY J WAHL LMT
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Gender | Female
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Dates
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Enumeration Date | 08/14/2012
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Last Update Date | 08/14/2012
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Provider Practice Location Address
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Address Line | 3083 WILLIAM ST SUITE 4
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City | CHEEKTOWAGA
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State | NY
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Zip | 14227-1933
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Country | US
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Telephone | 716-544-0753
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Fax | 716-783-8727
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Provider Business Mailing Address
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Address Line | 3083 WILLIAM STREET SUITE 4
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City | CHEEKTOWAGA
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State | NY
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Zip | 14227
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Country | US
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Telephone | 716-544-0753
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Fax | 716-783-8727
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225700000X
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Taxonomy Name | Massage Therapist
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License Number | 020632-1
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License Number State | NY
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