Provider Demographics
NPI:1245860170
Name:KOLACK, KRISTIN LADD (OTR/L)
Entity type:Individual
Prefix:
First Name:KRISTIN
Middle Name:LADD
Last Name:KOLACK
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:277 COOPER HILL RD
Mailing Address - Street 2:
Mailing Address - City:SOUTHBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06488-4652
Mailing Address - Country:US
Mailing Address - Phone:203-592-3439
Mailing Address - Fax:
Practice Address - Street 1:113 ELM ST STE 201
Practice Address - Street 2:
Practice Address - City:ENFIELD
Practice Address - State:CT
Practice Address - Zip Code:06082-3739
Practice Address - Country:US
Practice Address - Phone:860-253-5196
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-20
Last Update Date:2020-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT5375225XH1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XH1200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistHand