Provider Demographics
NPI:1114734688
Name:GOLLER, KEVIN (DPT)
Entity type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:
Last Name:GOLLER
Suffix:
Gender:
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15400 W GOODYEAR BLVD N APT 267
Mailing Address - Street 2:
Mailing Address - City:GOODYEAR
Mailing Address - State:AZ
Mailing Address - Zip Code:85338-1549
Mailing Address - Country:US
Mailing Address - Phone:925-325-6130
Mailing Address - Fax:
Practice Address - Street 1:5131 FOOTHILLS BLVD STE 5
Practice Address - Street 2:
Practice Address - City:ROSEVILLE
Practice Address - State:CA
Practice Address - Zip Code:95747-6527
Practice Address - Country:US
Practice Address - Phone:916-797-2273
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-12-17
Last Update Date:2025-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ033906225100000X
CA308075225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty