Healthcare Provider Details

I. General information

NPI: 1932401858
Provider Name (Legal Business Name): CHERYL MARIE COLLIER P.T.A.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/29/2010
Last Update Date: 04/08/2020
Certification Date: 04/08/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

306 WHARF ST
BROOKINGS OR
97415-0401
US

IV. Provider business mailing address

1207 MOORE ST APT 6
BROOKINGS OR
97415-9000
US

V. Phone/Fax

Practice location:
  • Phone: 541-469-0405
  • Fax:
Mailing address:
  • Phone: 707-951-4621
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number7400
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: