Provider Demographics
NPI:1326245309
Name:KOLONICH, MICHAEL A (COTAL)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:A
Last Name:KOLONICH
Suffix:
Gender:M
Credentials:COTAL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:145 HUNT CLUB DR
Mailing Address - Street 2:APT 3C
Mailing Address - City:COPLEY
Mailing Address - State:OH
Mailing Address - Zip Code:44321-2912
Mailing Address - Country:US
Mailing Address - Phone:330-603-4679
Mailing Address - Fax:
Practice Address - Street 1:575 S CLEVELAND MASSILLON RD
Practice Address - Street 2:
Practice Address - City:FAIRLAWN
Practice Address - State:OH
Practice Address - Zip Code:44333-3019
Practice Address - Country:US
Practice Address - Phone:330-666-5866
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-07-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHOTA01765224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0139424Medicaid