Provider Demographics
NPI:1811696024
Name:KOHLENBERG, RAYNE NIKOLE (PTA)
Entity type:Individual
Prefix:
First Name:RAYNE
Middle Name:NIKOLE
Last Name:KOHLENBERG
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3323 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BURGOON
Mailing Address - State:OH
Mailing Address - Zip Code:43407-9701
Mailing Address - Country:US
Mailing Address - Phone:419-307-3113
Mailing Address - Fax:
Practice Address - Street 1:45 ST LAWRENCE DR
Practice Address - Street 2:
Practice Address - City:TIFFIN
Practice Address - State:OH
Practice Address - Zip Code:44883-8310
Practice Address - Country:US
Practice Address - Phone:419-445-7000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-02-27
Last Update Date:2023-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPTA013427225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant