Provider Demographics
NPI:1427484922
Name:KOTARSKI, MICHELLE LYNN (PTA)
Entity type:Individual
Prefix:MRS
First Name:MICHELLE
Middle Name:LYNN
Last Name:KOTARSKI
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:MISS
Other - First Name:MICHELLE
Other - Middle Name:LYNN
Other - Last Name:ZINDA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PTA
Mailing Address - Street 1:2626 N 76TH ST
Mailing Address - Street 2:
Mailing Address - City:WAUWATOSA
Mailing Address - State:WI
Mailing Address - Zip Code:53213-1137
Mailing Address - Country:US
Mailing Address - Phone:414-774-7794
Mailing Address - Fax:414-607-3971
Practice Address - Street 1:2727 N GRANDVIEW BLVD
Practice Address - Street 2:SUITE 100
Practice Address - City:WAUKESHA
Practice Address - State:WI
Practice Address - Zip Code:53188-6100
Practice Address - Country:US
Practice Address - Phone:414-774-7794
Practice Address - Fax:414-607-3971
Is Sole Proprietor?:No
Enumeration Date:2013-09-17
Last Update Date:2013-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1226-19225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant