Healthcare Provider Details

I. General information

NPI: 1205033081
Provider Name (Legal Business Name): COLLINSVILLE PHYSICAL THERAPY & WELLNESS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/27/2007
Last Update Date: 11/02/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 UNITED DR SUITE 100
COLLINSVILLE IL
62234-7434
US

IV. Provider business mailing address

PO BOX 1007
GOSHEN NY
10924-8007
US

V. Phone/Fax

Practice location:
  • Phone: 618-343-1122
  • Fax: 618-343-1444
Mailing address:
  • Phone: 845-615-1585
  • Fax: 845-615-1576

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State

VIII. Authorized Official

Name: CHRISTOPHER J ALBANESE
Title or Position: SECRETARY
Credential: PT
Phone: 845-615-1585