Provider Demographics
NPI:1548668379
Name:WALLAU, KRISTIN (COTA/L)
Entity type:Individual
Prefix:
First Name:KRISTIN
Middle Name:
Last Name:WALLAU
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 1:835 TENDERFOOT HILL RD
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80906-3903
Mailing Address - Country:US
Mailing Address - Phone:719-576-8380
Mailing Address - Fax:
Practice Address - Street 1:835 TENDERFOOT HILL RD
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80906-3903
Practice Address - Country:US
Practice Address - Phone:719-576-8380
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-12-10
Last Update Date:2014-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COOTA.0000543224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant