Healthcare Provider Details

I. General information

NPI: 1174356364
Provider Name (Legal Business Name): COLLESE DALEY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/22/2024
Last Update Date: 09/29/2025
Certification Date: 09/29/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

102 IRVING ST NW
WASHINGTON DC
20010-2921
US

IV. Provider business mailing address

13705 CAMELOT FIELD DR
BOWIE MD
20720-5823
US

V. Phone/Fax

Practice location:
  • Phone: 202-877-1760
  • Fax:
Mailing address:
  • Phone: 240-676-6558
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: