Provider Demographics
NPI:1962233379
Name:JOHNSON, KOLLIN (DPT)
Entity type:Individual
Prefix:
First Name:KOLLIN
Middle Name:
Last Name:JOHNSON
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 1:1939 MINNEHAHA AVE W STE 300
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55104-1033
Mailing Address - Country:US
Mailing Address - Phone:651-748-4338
Mailing Address - Fax:651-748-2892
Practice Address - Street 1:1700 TOWER DR W
Practice Address - Street 2:
Practice Address - City:STILLWATER
Practice Address - State:MN
Practice Address - Zip Code:55082-7529
Practice Address - Country:US
Practice Address - Phone:651-275-4706
Practice Address - Fax:651-439-7173
Is Sole Proprietor?:No
Enumeration Date:2024-08-08
Last Update Date:2025-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI17069-24225100000X
MN13639225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist