Provider Demographics
NPI:1578016234
Name:KOSLICKI, LISA (DPT)
Entity type:Individual
Prefix:DR
First Name:LISA
Middle Name:
Last Name:KOSLICKI
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2675 NE LANCASTER ST APT 110
Mailing Address - Street 2:
Mailing Address - City:CORVALLIS
Mailing Address - State:OR
Mailing Address - Zip Code:97330-4149
Mailing Address - Country:US
Mailing Address - Phone:541-260-3909
Mailing Address - Fax:
Practice Address - Street 1:732 MAIN ST
Practice Address - Street 2:
Practice Address - City:PHILOMATH
Practice Address - State:OR
Practice Address - Zip Code:97370-9725
Practice Address - Country:US
Practice Address - Phone:541-929-2255
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-07-29
Last Update Date:2016-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR61870225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist