Provider Demographics
NPI:1922109586
Name:KOLLWELTER, KIMBERLY A (PT)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:A
Last Name:KOLLWELTER
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 1:790 REMINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60440-4909
Mailing Address - Country:US
Mailing Address - Phone:630-296-2223
Mailing Address - Fax:
Practice Address - Street 1:3082 CATON FARM RD
Practice Address - Street 2:
Practice Address - City:JOLIET
Practice Address - State:IL
Practice Address - Zip Code:60435-1455
Practice Address - Country:US
Practice Address - Phone:815-577-9936
Practice Address - Fax:815-577-9938
Is Sole Proprietor?:No
Enumeration Date:2006-09-26
Last Update Date:2011-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070013991225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILP00931590OtherMEDICARE RAILROAD
ILK53172Medicare PIN
ILP00931590OtherMEDICARE RAILROAD
ILK10581Medicare PIN
ILK53173Medicare PIN
IL202845100Medicare PIN