Healthcare Provider Details

I. General information

NPI: 1124597901
Provider Name (Legal Business Name): TERYN ANTHONY COLLINS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/21/2018
Last Update Date: 12/26/2023
Certification Date: 12/26/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4195 N VIKING WAY STE F&G
LONG BEACH CA
90808-1466
US

IV. Provider business mailing address

4195 N VIKING WAY STE F&G
LONG BEACH CA
90808-1466
US

V. Phone/Fax

Practice location:
  • Phone: 562-420-2112
  • Fax: 818-241-6853
Mailing address:
  • Phone: 562-420-2112
  • Fax: 818-241-6853

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number304450
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: