Provider Demographics
NPI:1053855114
Name:COLSTROM, SU (CPTA)
Entity Type:Individual
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First Name:SU
Middle Name:
Last Name:COLSTROM
Suffix:
Gender:F
Credentials:CPTA
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Mailing Address - Street 1:104 W MARKET ST
Mailing Address - Street 2:SUITE B
Mailing Address - City:OSAGE CITY
Mailing Address - State:KS
Mailing Address - Zip Code:66523-1277
Mailing Address - Country:US
Mailing Address - Phone:785-528-1123
Mailing Address - Fax:785-528-4123
Practice Address - Street 1:104 W MARKET ST
Practice Address - Street 2:SUITE B
Practice Address - City:OSAGE CITY
Practice Address - State:KS
Practice Address - Zip Code:66523-1277
Practice Address - Country:US
Practice Address - Phone:785-528-1123
Practice Address - Fax:785-528-4123
Is Sole Proprietor?:No
Enumeration Date:2016-12-08
Last Update Date:2016-12-08
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
KS14-01837225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant