Provider Demographics
NPI:1730809443
Name:GAYGEN, KELLY SUE (PT)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:SUE
Last Name:GAYGEN
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:
Other - Last Name:GAYGEN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:KELLY GAYGEN, BSPT
Mailing Address - Street 1:PO BOX 287
Mailing Address - Street 2:
Mailing Address - City:GASPORT
Mailing Address - State:NY
Mailing Address - Zip Code:14067
Mailing Address - Country:US
Mailing Address - Phone:716-255-6262
Mailing Address - Fax:
Practice Address - Street 1:8410 MAPLEWOOD DRIVE
Practice Address - Street 2:
Practice Address - City:GASPORT
Practice Address - State:NY
Practice Address - Zip Code:14067-0287
Practice Address - Country:US
Practice Address - Phone:716-280-1454
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-01
Last Update Date:2023-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY008684-1225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist