Provider Demographics
NPI:1639190648
Name:KOSOLA, SCOTT (DPT)
Entity Type:Individual
Prefix:
First Name:SCOTT
Middle Name:
Last Name:KOSOLA
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4663 W 20TH STREET RD
Mailing Address - Street 2:
Mailing Address - City:GREELEY
Mailing Address - State:CO
Mailing Address - Zip Code:80634-3246
Mailing Address - Country:US
Mailing Address - Phone:970-352-8762
Mailing Address - Fax:970-353-2081
Practice Address - Street 1:4663 W 20TH STREET RD
Practice Address - Street 2:
Practice Address - City:GREELEY
Practice Address - State:CO
Practice Address - Zip Code:80634-3246
Practice Address - Country:US
Practice Address - Phone:970-352-8762
Practice Address - Fax:970-353-2081
Is Sole Proprietor?:No
Enumeration Date:2006-07-22
Last Update Date:2009-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO8575225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
COC538118Medicare ID - Type Unspecified