Provider Demographics
NPI:1114049061
Name:BOLLIVAR, BRENDA KAY (DT)
Entity Type:Individual
Prefix:MRS
First Name:BRENDA
Middle Name:KAY
Last Name:BOLLIVAR
Suffix:
Gender:F
Credentials:DT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18410 HURD ROAD
Mailing Address - Street 2:
Mailing Address - City:PROPHETSTOWN
Mailing Address - State:IL
Mailing Address - Zip Code:61277-9379
Mailing Address - Country:US
Mailing Address - Phone:815-537-2530
Mailing Address - Fax:
Practice Address - Street 1:2300 WEST LEFEVRE ROAD
Practice Address - Street 2:
Practice Address - City:STERLING
Practice Address - State:IL
Practice Address - Zip Code:61081-7703
Practice Address - Country:US
Practice Address - Phone:815-626-3115
Practice Address - Fax:815-626-9640
Is Sole Proprietor?:No
Enumeration Date:2007-04-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILBB94480598P222Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist