Healthcare Provider Details

I. General information

NPI: 1154963445
Provider Name (Legal Business Name): COLLIN WOLLENMANN DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/08/2019
Last Update Date: 10/08/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1725 N 5TH ST
TERRE HAUTE IN
47804-4010
US

IV. Provider business mailing address

1100 SPRUCE ST APT 9
TERRE HAUTE IN
47807-2152
US

V. Phone/Fax

Practice location:
  • Phone: 812-242-3005
  • Fax:
Mailing address:
  • Phone: 812-630-7180
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number05013483A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: