Provider Demographics
NPI:1487816849
Name:BURR, KOLLEEN T (PT)
Entity Type:Individual
Prefix:
First Name:KOLLEEN
Middle Name:T
Last Name:BURR
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7388 AQUARIUS DR
Mailing Address - Street 2:
Mailing Address - City:MOHAVE VALLEY
Mailing Address - State:AZ
Mailing Address - Zip Code:86440-9101
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5300 HWY 95
Practice Address - Street 2:SUITE J
Practice Address - City:FORT MOHAVE
Practice Address - State:AZ
Practice Address - Zip Code:86426-9251
Practice Address - Country:US
Practice Address - Phone:928-788-3604
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-06-27
Last Update Date:2008-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ3542 PT225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist