Provider Demographics
NPI:1326119678
Name:KOSIOR, KENNETH A JR (MPT, ATC)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:A
Last Name:KOSIOR
Suffix:JR
Gender:M
Credentials:MPT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:47 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WEST HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06107-1926
Mailing Address - Country:US
Mailing Address - Phone:860-409-4595
Mailing Address - Fax:860-409-4860
Practice Address - Street 1:385 CHURCH ST STE 103
Practice Address - Street 2:
Practice Address - City:GUILFORD
Practice Address - State:CT
Practice Address - Zip Code:06437
Practice Address - Country:US
Practice Address - Phone:203-453-2844
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-10
Last Update Date:2019-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT8107225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ382617193OtherTAX ID NUMBER
AZ036551Medicare ID - Type UnspecifiedMEDICARE PROVIDER ID