Provider Demographics
NPI:1851364863
Name:OLIVER, COLLEEN M (RPT)
Entity Type:Individual
Prefix:
First Name:COLLEEN
Middle Name:M
Last Name:OLIVER
Suffix:
Gender:F
Credentials:RPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19415 US HIGHWAY 12
Mailing Address - Street 2:
Mailing Address - City:LEMMON
Mailing Address - State:SD
Mailing Address - Zip Code:57638-6303
Mailing Address - Country:US
Mailing Address - Phone:605-850-1532
Mailing Address - Fax:605-374-5666
Practice Address - Street 1:204 S 4TH AVE W
Practice Address - Street 2:
Practice Address - City:FAITH
Practice Address - State:SD
Practice Address - Zip Code:57626-6038
Practice Address - Country:US
Practice Address - Phone:605-374-5844
Practice Address - Fax:605-374-9524
Is Sole Proprietor?:No
Enumeration Date:2006-02-09
Last Update Date:2021-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD0468225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND52628OtherND MEDICAID
SD5830960Medicaid
SD4999695OtherWELLMARK BCBS OF SD
SD650023807OtherRAILROAD MEDICARE