Provider Demographics
NPI:1912625138
Name:KICZEK, CHRISTINA BERNADETTE (COTA/L)
Entity Type:Individual
Prefix:
First Name:CHRISTINA
Middle Name:BERNADETTE
Last Name:KICZEK
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 1:5609 AMAYA DR APT 217
Mailing Address - Street 2:
Mailing Address - City:LA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:91942-3684
Mailing Address - Country:US
Mailing Address - Phone:619-597-9092
Mailing Address - Fax:
Practice Address - Street 1:4500 E CHERRY CREEK SOUTH DR STE 710
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:CO
Practice Address - Zip Code:80246-1534
Practice Address - Country:US
Practice Address - Phone:303-432-8487
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-15
Last Update Date:2022-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COOTA.0001602224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant