Provider Demographics
NPI:1912022823
Name:KOSTIAK, COLLEEN DEE (PT)
Entity Type:Individual
Prefix:MRS
First Name:COLLEEN
Middle Name:DEE
Last Name:KOSTIAK
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2744 DARK REGION RD.
Mailing Address - Street 2:
Mailing Address - City:CLARKS SUMMIT
Mailing Address - State:PA
Mailing Address - Zip Code:18411-9633
Mailing Address - Country:US
Mailing Address - Phone:570-587-2777
Mailing Address - Fax:
Practice Address - Street 1:150 EDELLA RD
Practice Address - Street 2:
Practice Address - City:CLARKS SUMMIT
Practice Address - State:PA
Practice Address - Zip Code:18411-1628
Practice Address - Country:US
Practice Address - Phone:570-585-2494
Practice Address - Fax:570-587-3308
Is Sole Proprietor?:No
Enumeration Date:2007-03-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPT017714225100000X
MD17493225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist