Provider Demographics
NPI:1629208376
Name:KOSTELECKY, CHRISTAN MICHELLE
Entity Type:Individual
Prefix:
First Name:CHRISTAN
Middle Name:MICHELLE
Last Name:KOSTELECKY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:CHRISSY
Other - Middle Name:
Other - Last Name:KOSTELECKY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:815 S BRIDGE WAY PL
Mailing Address - Street 2:STE 122
Mailing Address - City:EAGLE
Mailing Address - State:ID
Mailing Address - Zip Code:83616-6022
Mailing Address - Country:US
Mailing Address - Phone:208-972-0918
Mailing Address - Fax:
Practice Address - Street 1:4606 N COLLEGE DR
Practice Address - Street 2:
Practice Address - City:CHEYENNE
Practice Address - State:WY
Practice Address - Zip Code:82009-5456
Practice Address - Country:US
Practice Address - Phone:307-414-8394
Practice Address - Fax:307-316-8125
Is Sole Proprietor?:No
Enumeration Date:2009-07-15
Last Update Date:2018-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WYOT-833225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist