Provider Demographics
NPI:1659320414
Name:COLLISTER, ANITA K (OTR)
Entity Type:Individual
Prefix:
First Name:ANITA
Middle Name:K
Last Name:COLLISTER
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1363 E 1048 RD
Mailing Address - Street 2:
Mailing Address - City:LAWRENCE
Mailing Address - State:KS
Mailing Address - Zip Code:66047-9648
Mailing Address - Country:US
Mailing Address - Phone:785-842-7318
Mailing Address - Fax:
Practice Address - Street 1:4101 S 4TH STREET TRAFFICWAY
Practice Address - Street 2:
Practice Address - City:LEAVENWORTH
Practice Address - State:KS
Practice Address - Zip Code:66048-9951
Practice Address - Country:US
Practice Address - Phone:913-682-2000
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS17-00050225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist