Healthcare Provider Details

I. General information

NPI: 1528480928
Provider Name (Legal Business Name): ALYSE KOLSTAD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/20/2014
Last Update Date: 08/04/2026
Certification Date: 08/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

W259N9116 STATE ROAD 164
HARTLAND WI
53029-9010
US

IV. Provider business mailing address

PO BOX 711185
SALT LAKE CITY UT
84171-1185
US

V. Phone/Fax

Practice location:
  • Phone: 360-951-6883
  • Fax:
Mailing address:
  • Phone: 801-942-3311
  • Fax: 801-942-5955

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License NumberOT60340484
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: