Provider Demographics
NPI:1568716843
Name:KOLODJAY, CAMILLE WONIYA (DPT)
Entity Type:Individual
Prefix:MS
First Name:CAMILLE
Middle Name:WONIYA
Last Name:KOLODJAY
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13790 GAS CANYON RD
Mailing Address - Street 2:
Mailing Address - City:NEVADA CITY
Mailing Address - State:CA
Mailing Address - Zip Code:95959-8843
Mailing Address - Country:US
Mailing Address - Phone:707-499-4418
Mailing Address - Fax:
Practice Address - Street 1:300 SIERRA COLLEGE DR
Practice Address - Street 2:SUITE 165
Practice Address - City:GRASS VALLEY
Practice Address - State:CA
Practice Address - Zip Code:95945-5082
Practice Address - Country:US
Practice Address - Phone:530-274-2320
Practice Address - Fax:530-274-1568
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-07
Last Update Date:2013-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT37228225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPT37228OtherPHYSICAL THERAPIST
CAPT37228OtherPHYSICAL THERAPIST