Provider Demographics
NPI:1710215777
Name:ELLIOTT, COLLEEN ROSE (PT)
Entity type:Individual
Prefix:
First Name:COLLEEN
Middle Name:ROSE
Last Name:ELLIOTT
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:COLEEN
Other - Middle Name:ROSE
Other - Last Name:KORNAHRENS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:518 VANDERBILT DR
Mailing Address - Street 2:
Mailing Address - City:PLACENTIA
Mailing Address - State:CA
Mailing Address - Zip Code:92870-5118
Mailing Address - Country:US
Mailing Address - Phone:714-404-9474
Mailing Address - Fax:
Practice Address - Street 1:1700 ADAMS AVE
Practice Address - Street 2:201
Practice Address - City:COSTA MESA
Practice Address - State:CA
Practice Address - Zip Code:92626-4865
Practice Address - Country:US
Practice Address - Phone:714-556-1600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-12-01
Last Update Date:2012-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA324902251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic