Healthcare Provider Details

I. General information

NPI: 1851947386
Provider Name (Legal Business Name): SUSAN AYRES KOLBUSZ OTR/L
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: SUSAN LOCKWOOD AYRES OTR/L

II. Dates (important events)

Enumeration Date: 08/12/2019
Last Update Date: 08/12/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2 RUE NICOLE
BARKHAMSTED CT
06063
US

IV. Provider business mailing address

2 RUE NICOLE
BARKHAMSTED CT
06063-3359
US

V. Phone/Fax

Practice location:
  • Phone: 860-416-4447
  • Fax:
Mailing address:
  • Phone: 860-416-4447
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License NumberOTR3256
License Number StateAR
# 2
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License NumberOT007221
License Number StateGA
# 3
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number002451
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: