Healthcare Provider Details

I. General information

NPI: 1952050775
Provider Name (Legal Business Name): MARTHA RENEE COLLIER LPTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/20/2022
Last Update Date: 03/20/2022
Certification Date: 03/20/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1902 HAND AVE STE C
BAY MINETTE AL
36507-4113
US

IV. Provider business mailing address

10388 ROSEWOOD LN
DAPHNE AL
36526-6654
US

V. Phone/Fax

Practice location:
  • Phone: 251-239-5395
  • Fax:
Mailing address:
  • Phone: 251-753-4006
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2081S0010X
TaxonomySports Medicine (Physical Medicine & Rehabilitation) Physician
License Number9199
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: