Healthcare Provider Details

I. General information

NPI: 1568830719
Provider Name (Legal Business Name): COLLIN WILLIAM WALLACE DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/04/2015
Last Update Date: 11/18/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2349 SUNSET POINT RD STE 400
CLEARWATER FL
33765-1439
US

IV. Provider business mailing address

3903 NORTHDALE BLVD STE 111W
TAMPA FL
33624-1853
US

V. Phone/Fax

Practice location:
  • Phone: 970-371-8965
  • Fax:
Mailing address:
  • Phone: 813-805-8167
  • Fax: 844-214-1382

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number30787
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: