Provider Demographics
NPI:1083860621
Name:KOZLOSKI, CHERISSE A (PTA)
Entity Type:Individual
Prefix:
First Name:CHERISSE
Middle Name:A
Last Name:KOZLOSKI
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 1:59 EDEN AVE
Mailing Address - Street 2:
Mailing Address - City:SOUTHINGTON
Mailing Address - State:CT
Mailing Address - Zip Code:06489-4512
Mailing Address - Country:US
Mailing Address - Phone:203-592-2160
Mailing Address - Fax:860-426-1414
Practice Address - Street 1:59 EDEN AVE
Practice Address - Street 2:
Practice Address - City:SOUTHINGTON
Practice Address - State:CT
Practice Address - Zip Code:06489-4512
Practice Address - Country:US
Practice Address - Phone:203-592-2160
Practice Address - Fax:860-426-1414
Is Sole Proprietor?:No
Enumeration Date:2008-08-14
Last Update Date:2008-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000971225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant