Provider Demographics
NPI:1518237478
Name:KOLOKOLLIE, LEESOLEE
Entity Type:Individual
Prefix:
First Name:LEESOLEE
Middle Name:
Last Name:KOLOKOLLIE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5633 25TH STREET CIR E
Mailing Address - Street 2:
Mailing Address - City:BRADENTON
Mailing Address - State:FL
Mailing Address - Zip Code:34203-4910
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5633 25TH STREET CIR E
Practice Address - Street 2:
Practice Address - City:BRADENTON
Practice Address - State:FL
Practice Address - Zip Code:34203-4910
Practice Address - Country:US
Practice Address - Phone:941-580-2461
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-10
Last Update Date:2012-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOTA11368224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLOTA 11368OtherFLORIDA