Provider Demographics
NPI:1619480258
Name:KNICLEY SE, LLC
Entity type:Organization
Organization Name:KNICLEY SE, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PT, OWNER, OPERATOR
Authorized Official - Prefix:
Authorized Official - First Name:JASON
Authorized Official - Middle Name:
Authorized Official - Last Name:KNICLEY
Authorized Official - Suffix:
Authorized Official - Credentials:PT, DPT
Authorized Official - Phone:301-992-6797
Mailing Address - Street 1:10938 LOUIS DETRICK LN
Mailing Address - Street 2:
Mailing Address - City:MONROVIA
Mailing Address - State:MD
Mailing Address - Zip Code:21770-6030
Mailing Address - Country:US
Mailing Address - Phone:301-992-6797
Mailing Address - Fax:
Practice Address - Street 1:3540 SUGARLOAF PKWY STE D03
Practice Address - Street 2:
Practice Address - City:FREDERICK
Practice Address - State:MD
Practice Address - Zip Code:21704-7901
Practice Address - Country:US
Practice Address - Phone:301-992-6797
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-11-06
Last Update Date:2021-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD234762251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedicGroup - Multi-Specialty