Healthcare Provider Details

I. General information

NPI: 1164036356
Provider Name (Legal Business Name): MARJORIE COLLINS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/04/2020
Last Update Date: 09/04/2020
Certification Date: 09/03/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5981 SE WINDSONG LN
STUART FL
34997-8262
US

IV. Provider business mailing address

5981 SE WINDSONG LN
STUART FL
34997-8262
US

V. Phone/Fax

Practice location:
  • Phone: 772-713-7982
  • Fax:
Mailing address:
  • Phone: 772-713-7982
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMA-77145
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: