Provider Demographics
NPI:1386612885
Name:KIMOFF, COLLEEN DOROTHY (PT)
Entity type:Individual
Prefix:
First Name:COLLEEN
Middle Name:DOROTHY
Last Name:KIMOFF
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:790 REMINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60440-4909
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9500 SE 82ND AVE STE B
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97086-3746
Practice Address - Country:US
Practice Address - Phone:971-323-6234
Practice Address - Fax:503-386-8214
Is Sole Proprietor?:No
Enumeration Date:2006-03-09
Last Update Date:2022-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR3820225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR232005Medicaid
OR232005Medicaid