Provider Demographics
NPI:1720205420
Name:KOLESAR, DIANE MARIE (OT)
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:MARIE
Last Name:KOLESAR
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2120 EXETER RD STE 110
Mailing Address - Street 2:
Mailing Address - City:GERMANTOWN
Mailing Address - State:TN
Mailing Address - Zip Code:38138-3900
Mailing Address - Country:US
Mailing Address - Phone:901-624-8677
Mailing Address - Fax:901-624-8676
Practice Address - Street 1:2195 TEALSTONE DR
Practice Address - Street 2:
Practice Address - City:GERMANTOWN
Practice Address - State:TN
Practice Address - Zip Code:38139-3552
Practice Address - Country:US
Practice Address - Phone:901-757-4181
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNOT0000001872225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist