Provider Demographics
NPI:1962630038
Name:KELM, COLLEEN ROSE (DPT)
Entity Type:Individual
Prefix:
First Name:COLLEEN
Middle Name:ROSE
Last Name:KELM
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:COLLEEN
Other - Middle Name:ROSE
Other - Last Name:PHILLIPP
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DPT
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 1:4861 S 27TH ST
Practice Address - Street 2:
Practice Address - City:GREENFIELD
Practice Address - State:WI
Practice Address - Zip Code:53221-2603
Practice Address - Country:US
Practice Address - Phone:414-325-3325
Practice Address - Fax:414-325-3334
Is Sole Proprietor?:No
Enumeration Date:2009-06-29
Last Update Date:2014-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI11325-024225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WIP00920110OtherMEDICARE RAILROAD
WI830420027Medicare PIN
WI830420052Medicare PIN
WIP00920110OtherMEDICARE RAILROAD