Provider Demographics
NPI:1942386487
Name:KOZELISKI, LEANN GAYLE (COTA/L)
Entity Type:Individual
Prefix:MRS
First Name:LEANN
Middle Name:GAYLE
Last Name:KOZELISKI
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23801 N 35TH DR
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85310-4169
Mailing Address - Country:US
Mailing Address - Phone:623-580-8526
Mailing Address - Fax:
Practice Address - Street 1:10251 N 35TH AVE
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85051-1305
Practice Address - Country:US
Practice Address - Phone:602-995-7366
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ3257224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ1051728OtherCOTA CERT.