Provider Demographics
NPI:1548607831
Name:KUSSARD, COLLEEN HEATHER (DPT)
Entity Type:Individual
Prefix:
First Name:COLLEEN
Middle Name:HEATHER
Last Name:KUSSARD
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:COLLEEN
Other - Middle Name:HEATHER
Other - Last Name:DAVIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DPT
Mailing Address - Street 1:20 PEACHTREE CT
Mailing Address - Street 2:SUITE 105
Mailing Address - City:HOLBROOK
Mailing Address - State:NY
Mailing Address - Zip Code:11741-4616
Mailing Address - Country:US
Mailing Address - Phone:631-467-3700
Mailing Address - Fax:
Practice Address - Street 1:1715 CASTLE GARDENS RD
Practice Address - Street 2:
Practice Address - City:VESTAL
Practice Address - State:NY
Practice Address - Zip Code:13850-1175
Practice Address - Country:US
Practice Address - Phone:607-484-5079
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-05-28
Last Update Date:2016-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY036375225100000X
PAPT0226922251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic