Provider Demographics
NPI:1720066780
Name:KOLBECK, KARL JAMES (PT)
Entity Type:Individual
Prefix:MR
First Name:KARL
Middle Name:JAMES
Last Name:KOLBECK
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25 NW 23RD PL
Mailing Address - Street 2:STE 6 - 311
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97210-5580
Mailing Address - Country:US
Mailing Address - Phone:503-913-4450
Mailing Address - Fax:866-866-1976
Practice Address - Street 1:1515 NW 18TH AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97209-2516
Practice Address - Country:US
Practice Address - Phone:503-228-1306
Practice Address - Fax:503-228-1307
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-09
Last Update Date:2012-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR2675225100000X
WI4199225100000X
WAPT00005973225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR158552Medicaid
OR158552Medicaid