Healthcare Provider Details

I. General information

NPI: 1104493949
Provider Name (Legal Business Name): COLLIN DEAN PT, DPT, ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/09/2021
Last Update Date: 07/10/2024
Certification Date: 07/10/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2103 W PARKSIDE LN STE 103
PHOENIX AZ
85027-1245
US

IV. Provider business mailing address

2103 W PARKSIDE LN STE 103
PHOENIX AZ
85027-1245
US

V. Phone/Fax

Practice location:
  • Phone: 540-236-2734
  • Fax:
Mailing address:
  • Phone: 540-236-2734
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: