Provider Demographics
NPI:1255827119
Name:KOLL, DEREK
Entity Type:Individual
Prefix:
First Name:DEREK
Middle Name:
Last Name:KOLL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 737
Mailing Address - Street 2:
Mailing Address - City:HOWARD LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:55349-0737
Mailing Address - Country:US
Mailing Address - Phone:320-543-1103
Mailing Address - Fax:320-543-1105
Practice Address - Street 1:109 5TH ST NE
Practice Address - Street 2:
Practice Address - City:LITTLE FALLS
Practice Address - State:MN
Practice Address - Zip Code:56345-2732
Practice Address - Country:US
Practice Address - Phone:320-631-1104
Practice Address - Fax:320-631-1105
Is Sole Proprietor?:No
Enumeration Date:2018-07-03
Last Update Date:2023-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN11754225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist