Basic Information
| Provider Information | |||||||||
| NPI: | 1407934359 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KOKOLIS | ||||||||
| FirstName: | JOANNA | ||||||||
| MiddleName: | M. | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PT, DPT | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MICHALOPULOS | ||||||||
| OtherFirstName: | JOANNA | ||||||||
| OtherMiddleName: | U. | ||||||||
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| OtherCredential: | PT,DPT | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 771 PILOT HOUSE DR | ||||||||
| Address2: | SUITE A | ||||||||
| City: | NEWPORT NEWS | ||||||||
| State: | VA | ||||||||
| PostalCode: | 236061990 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7578732302 | ||||||||
| FaxNumber: | 7578732306 | ||||||||
| Practice Location | |||||||||
| Address1: | 4125 IRONBOUND RD | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | WILLIAMSBURG | ||||||||
| State: | VA | ||||||||
| PostalCode: | 231882666 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7572208383 | ||||||||
| FaxNumber: | 7572537833 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/01/2006 | ||||||||
| LastUpdateDate: | 02/01/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 1158690 | TX | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225100000X | 2305209311 | VA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | C05954 | 01 | VA | MEDICARE GROUP PTAN | OTHER | 1407934359 | 01 | VA | MEDICAID QMB | OTHER |