Provider Demographics
NPI:1245754308
Name:DEFREESE, KALEB JOEL (ATC, LAT)
Entity Type:Individual
Prefix:
First Name:KALEB
Middle Name:JOEL
Last Name:DEFREESE
Suffix:
Gender:M
Credentials:ATC, LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5606 BIG PAW HTS
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80919-3774
Mailing Address - Country:US
Mailing Address - Phone:574-612-3548
Mailing Address - Fax:
Practice Address - Street 1:1300 HIGBY RD
Practice Address - Street 2:
Practice Address - City:MONUMENT
Practice Address - State:CO
Practice Address - Zip Code:80132-7406
Practice Address - Country:US
Practice Address - Phone:719-488-4720
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-31
Last Update Date:2017-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COAT.00017092255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic TrainerGroup - Single Specialty