Provider Demographics
NPI:1063734473
Name:KOCZAK, LISA (DPT)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:KOCZAK
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:
Other - Last Name:VALLERA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DPT
Mailing Address - Street 1:2408 WHITNEY AVE
Mailing Address - Street 2:
Mailing Address - City:HAMDEN
Mailing Address - State:CT
Mailing Address - Zip Code:06518-3209
Mailing Address - Country:US
Mailing Address - Phone:203-626-0160
Mailing Address - Fax:203-294-6734
Practice Address - Street 1:2416 WHITNEY AVE
Practice Address - Street 2:
Practice Address - City:HAMDEN
Practice Address - State:CT
Practice Address - Zip Code:06518-3248
Practice Address - Country:US
Practice Address - Phone:203-407-3590
Practice Address - Fax:203-466-8527
Is Sole Proprietor?:No
Enumeration Date:2010-02-26
Last Update Date:2022-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT008736225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTD400212422Medicare Oscar/Certification