Provider Demographics
NPI:1073251765
Name:KOLESNIKOVA, MARIIA (PTA)
Entity Type:Individual
Prefix:
First Name:MARIIA
Middle Name:
Last Name:KOLESNIKOVA
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3555 RIALTO HTS APT 23
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80907-8618
Mailing Address - Country:US
Mailing Address - Phone:302-864-7067
Mailing Address - Fax:
Practice Address - Street 1:4328 AUSTIN BLUFFS PKWY
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80918-2932
Practice Address - Country:US
Practice Address - Phone:719-475-0808
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-24
Last Update Date:2022-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPTA.0015169225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
COPTA.0015169OtherCOLORADO DIVISION OF PROFESSIONS AND REGULATIONS