Provider Demographics
NPI:1790454411
Name:KOLMANOVSKIY, LISA ROSARIO (OTR/L)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:ROSARIO
Last Name:KOLMANOVSKIY
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:RIVERA
Other - Last Name:ROSARIO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OTR/L
Mailing Address - Street 1:188 HACKAMORE CMN
Mailing Address - Street 2:
Mailing Address - City:FREMONT
Mailing Address - State:CA
Mailing Address - Zip Code:94539-7477
Mailing Address - Country:US
Mailing Address - Phone:408-476-3717
Mailing Address - Fax:
Practice Address - Street 1:825 OAK GROVE AVE STE A102
Practice Address - Street 2:
Practice Address - City:MENLO PARK
Practice Address - State:CA
Practice Address - Zip Code:94025-4427
Practice Address - Country:US
Practice Address - Phone:650-323-0805
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-07
Last Update Date:2023-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA22506225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist