Healthcare Provider Details

I. General information

NPI: 1063734473
Provider Name (Legal Business Name): LISA KOCZAK DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: LISA VALLERA DPT

II. Dates (important events)

Enumeration Date: 02/26/2010
Last Update Date: 03/07/2022
Certification Date: 03/07/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2416 WHITNEY AVE
HAMDEN CT
06518-3248
US

IV. Provider business mailing address

2408 WHITNEY AVE
HAMDEN CT
06518-3209
US

V. Phone/Fax

Practice location:
  • Phone: 203-407-3590
  • Fax: 203-466-8527
Mailing address:
  • Phone: 203-626-0160
  • Fax: 203-294-6734

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number008736
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: