Provider Demographics
NPI:1992075279
Name:KOHLENBERGER, DOMINIQUE MADELEINE (PT)
Entity type:Individual
Prefix:
First Name:DOMINIQUE
Middle Name:MADELEINE
Last Name:KOHLENBERGER
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:PO BOX 1156
Mailing Address - Street 2:
Mailing Address - City:ELLENTON
Mailing Address - State:FL
Mailing Address - Zip Code:34222-1156
Mailing Address - Country:US
Mailing Address - Phone:941-729-0003
Mailing Address - Fax:941-729-0004
Practice Address - Street 1:4134 GULF OF MEXICO DR
Practice Address - Street 2:UNIT 209
Practice Address - City:LONGBOAT KEY
Practice Address - State:FL
Practice Address - Zip Code:34228-2642
Practice Address - Country:US
Practice Address - Phone:941-383-0414
Practice Address - Fax:941-383-0120
Is Sole Proprietor?:No
Enumeration Date:2012-01-04
Last Update Date:2012-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT 7196225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist