Provider Demographics
NPI:1780294579
Name:KOELLING, SAMUEL WARREN (DPT)
Entity type:Individual
Prefix:
First Name:SAMUEL
Middle Name:WARREN
Last Name:KOELLING
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5841 THUNDERBIRD RD STE I
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46236-4792
Mailing Address - Country:US
Mailing Address - Phone:317-823-0662
Mailing Address - Fax:
Practice Address - Street 1:5841 THUNDERBIRD RD STE I
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46236-4792
Practice Address - Country:US
Practice Address - Phone:317-823-0662
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-06
Last Update Date:2021-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN05013785A225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist