Healthcare Provider Details

I. General information

NPI: 1306819487
Provider Name (Legal Business Name): COLLEEN THOMAS PT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/09/2006
Last Update Date: 11/19/2021
Certification Date: 11/19/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3920 VETERANS MEMORIAL HWY SUITE 13
BOHEMIA NY
11716-1074
US

IV. Provider business mailing address

3920 VETERANS MEMORIAL HWY SUITE 13
BOHEMIA NY
11716-1074
US

V. Phone/Fax

Practice location:
  • Phone: 631-630-6485
  • Fax: 631-630-6486
Mailing address:
  • Phone: 631-630-6485
  • Fax: 631-630-6486

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number0183891
License Number StateNY

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: