Healthcare Provider Details

I. General information

NPI: 1073599791
Provider Name (Legal Business Name): STEPHANIE W COLLINS D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/15/2005
Last Update Date: 10/14/2024
Certification Date: 10/14/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

96 OCEAN ST STE 4
SOUTH PORTLAND ME
04106-2855
US

IV. Provider business mailing address

96 OCEAN ST STE 4
SOUTH PORTLAND ME
04106-2855
US

V. Phone/Fax

Practice location:
  • Phone: 207-747-4455
  • Fax: 888-907-5762
Mailing address:
  • Phone: 207-747-4455
  • Fax: 888-907-5762

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code204D00000X
TaxonomyNeuromusculoskeletal Medicine & OMM Physician
License NumberDO1663
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: