Provider Demographics
NPI:1265105548
Name:KOLKHORST, DEDRA BORMANN
Entity type:Individual
Prefix:
First Name:DEDRA
Middle Name:BORMANN
Last Name:KOLKHORST
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1400 PLEDGER RD
Mailing Address - Street 2:
Mailing Address - City:BRENHAM
Mailing Address - State:TX
Mailing Address - Zip Code:77833-7304
Mailing Address - Country:US
Mailing Address - Phone:979-203-9595
Mailing Address - Fax:
Practice Address - Street 1:604 HIGHWAY 290 E
Practice Address - Street 2:
Practice Address - City:BRENHAM
Practice Address - State:TX
Practice Address - Zip Code:77833
Practice Address - Country:US
Practice Address - Phone:979-337-5702
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-01
Last Update Date:2021-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist