Healthcare Provider Details

I. General information

NPI: 1386664043
Provider Name (Legal Business Name): PATRICIA MARIE COLLINS RD, CDE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/19/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

940 BELMONT ST
BROCKTON MA
02301-5596
US

IV. Provider business mailing address

14 AMARK RD
BROCKTON MA
02302-2149
US

V. Phone/Fax

Practice location:
  • Phone: 774-826-4000
  • Fax: 774-826-3157
Mailing address:
  • Phone: 774-826-2012
  • Fax: 774-826-3157

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133VN1006X
TaxonomyMetabolic Nutrition Registered Dietitian
License Number1943
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: