Healthcare Provider Details

I. General information

NPI: 1083872345
Provider Name (Legal Business Name): GEORGE RONALD KOCSIS JR. OTR/L
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/23/2008
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

PROVIDENCE ST. MARY MEDICAL CENTER 401 W. POPLAR ST.
WALLA WALLA WA
99362-4619
US

IV. Provider business mailing address

PROVIDENCE ST. MARY MEDICAL CENTER 401 W. POPLAR ST.
WALLA WALLA WA
99362
US

V. Phone/Fax

Practice location:
  • Phone: 509-897-2100
  • Fax: 509-897-5508
Mailing address:
  • Phone: 509-897-2100
  • Fax: 509-897-5508

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number113371
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License NumberOT-498
License Number StateID
# 3
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License NumberOT00002963
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: