Provider Demographics
NPI:1386195733
Name:WOLLENBERG, COLLEEN KAY (COTA/L)
Entity Type:Individual
Prefix:MRS
First Name:COLLEEN
Middle Name:KAY
Last Name:WOLLENBERG
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:29717 N 154TH ST
Mailing Address - Street 2:
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85262-7906
Mailing Address - Country:US
Mailing Address - Phone:602-680-2233
Mailing Address - Fax:602-639-4839
Practice Address - Street 1:29717 N 154TH ST
Practice Address - Street 2:
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85262-7906
Practice Address - Country:US
Practice Address - Phone:602-680-2233
Practice Address - Fax:602-639-4839
Is Sole Proprietor?:No
Enumeration Date:2016-10-20
Last Update Date:2016-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ0622224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant