Provider Demographics
NPI:1255576559
Name:KOSKODAN, JUDITH ANN (PT)
Entity type:Individual
Prefix:
First Name:JUDITH
Middle Name:ANN
Last Name:KOSKODAN
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:JUDITH
Other - Middle Name:A
Other - Last Name:SEBOLKA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:5314 BISHOP RD
Mailing Address - Street 2:
Mailing Address - City:DRYDEN
Mailing Address - State:MI
Mailing Address - Zip Code:48428-9335
Mailing Address - Country:US
Mailing Address - Phone:810-796-3796
Mailing Address - Fax:
Practice Address - Street 1:122 S MAIN ST
Practice Address - Street 2:
Practice Address - City:ALMONT
Practice Address - State:MI
Practice Address - Zip Code:48003-1066
Practice Address - Country:US
Practice Address - Phone:800-974-4378
Practice Address - Fax:630-515-1536
Is Sole Proprietor?:No
Enumeration Date:2008-12-16
Last Update Date:2021-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501007048225100000X, 235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist