Healthcare Provider Details

I. General information

NPI: 1053849828
Provider Name (Legal Business Name): JOSE ISMEL COLLADO PT, DPT, LMT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/24/2017
Last Update Date: 02/18/2025
Certification Date: 02/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

250 WESTPORT AVE
NORWALK CT
06851-4158
US

IV. Provider business mailing address

65 WEDGEWOOD PL
BRIDGEPORT CT
06606-1927
US

V. Phone/Fax

Practice location:
  • Phone: 917-515-0288
  • Fax:
Mailing address:
  • Phone: 917-515-0288
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number14775
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number007864
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: