Provider Demographics
NPI:1356460398
Name:KOHLRUS, KOLLEEN K (LMP)
Entity Type:Individual
Prefix:
First Name:KOLLEEN
Middle Name:K
Last Name:KOHLRUS
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3301 NE 11TH ST
Mailing Address - Street 2:
Mailing Address - City:RENTON
Mailing Address - State:WA
Mailing Address - Zip Code:98056-3452
Mailing Address - Country:US
Mailing Address - Phone:206-280-3519
Mailing Address - Fax:
Practice Address - Street 1:6300 STORKSON RD BLDG 2-B
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:WA
Practice Address - Zip Code:98236-9514
Practice Address - Country:US
Practice Address - Phone:360-221-8552
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-29
Last Update Date:2015-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00004101225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist