Provider Demographics
NPI:1831579366
Name:GOLLNICK, KRISTEN TESS (PT, DPT)
Entity type:Individual
Prefix:
First Name:KRISTEN
Middle Name:TESS
Last Name:GOLLNICK
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3301 W FOREST HOME AVE
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53215-2843
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1249 W LIEBAU RD
Practice Address - Street 2:
Practice Address - City:MEQUON
Practice Address - State:WI
Practice Address - Zip Code:53092-3396
Practice Address - Country:US
Practice Address - Phone:262-243-4161
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-05-29
Last Update Date:2022-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI13096-24225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist