Provider Demographics
NPI:1366525982
Name:KECKEISEN, PAUL HENRY (PTA)
Entity type:Individual
Prefix:MR
First Name:PAUL
Middle Name:HENRY
Last Name:KECKEISEN
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9 W SPRUCE ST
Mailing Address - Street 2:
Mailing Address - City:ISLIP
Mailing Address - State:NY
Mailing Address - Zip Code:11751-2713
Mailing Address - Country:US
Mailing Address - Phone:631-650-5572
Mailing Address - Fax:
Practice Address - Street 1:120 PLANT AVE
Practice Address - Street 2:
Practice Address - City:HAUPPAUGE
Practice Address - State:NY
Practice Address - Zip Code:11788-3805
Practice Address - Country:US
Practice Address - Phone:631-273-1300
Practice Address - Fax:631-851-3865
Is Sole Proprietor?:No
Enumeration Date:2006-10-24
Last Update Date:2010-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY002975225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant