Healthcare Provider Details

I. General information

NPI: 1326245309
Provider Name (Legal Business Name): MICHAEL A KOLONICH COTAL
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/02/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

575 S CLEVELAND MASSILLON RD
FAIRLAWN OH
44333-3019
US

IV. Provider business mailing address

145 HUNT CLUB DR APT 3C
COPLEY OH
44321-2912
US

V. Phone/Fax

Practice location:
  • Phone: 330-666-5866
  • Fax:
Mailing address:
  • Phone: 330-603-4679
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License NumberOTA01765
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: