Healthcare Provider Details

I. General information

NPI: 1578016234
Provider Name (Legal Business Name): LISA KOSLICKI DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/29/2016
Last Update Date: 07/29/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

732 MAIN ST
PHILOMATH OR
97370-9725
US

IV. Provider business mailing address

2675 NE LANCASTER ST APT 110
CORVALLIS OR
97330-4149
US

V. Phone/Fax

Practice location:
  • Phone: 541-929-2255
  • Fax:
Mailing address:
  • Phone: 541-260-3909
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number61870
License Number StateOR

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: