Provider Demographics
NPI:1972678613
Name:KOLETSOS, AGNES LYNNE (MOT OTRL)
Entity Type:Individual
Prefix:MRS
First Name:AGNES
Middle Name:LYNNE
Last Name:KOLETSOS
Suffix:
Gender:F
Credentials:MOT OTRL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:516 N WOODFIELD TRAIL
Mailing Address - Street 2:
Mailing Address - City:ROSELLE
Mailing Address - State:IL
Mailing Address - Zip Code:60172
Mailing Address - Country:US
Mailing Address - Phone:847-226-0193
Mailing Address - Fax:
Practice Address - Street 1:516 N WOODFIELD TRAIL
Practice Address - Street 2:
Practice Address - City:ROSELLE
Practice Address - State:IL
Practice Address - Zip Code:60172
Practice Address - Country:US
Practice Address - Phone:847-226-0193
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-21
Last Update Date:2008-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL056007678225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist