Provider Demographics
NPI:1104332956
Name:KAPUSTKA, KRISTIE RACHELLE (COTA)
Entity type:Individual
Prefix:MRS
First Name:KRISTIE
Middle Name:RACHELLE
Last Name:KAPUSTKA
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5054 FARRIS CREEK CT
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80924-2914
Mailing Address - Country:US
Mailing Address - Phone:719-573-7808
Mailing Address - Fax:719-573-7808
Practice Address - Street 1:5054 FARRIS CREEK CT
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80924-2914
Practice Address - Country:US
Practice Address - Phone:719-573-7808
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-15
Last Update Date:2017-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COOTA.0000105224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant