Basic Information
| Provider Information | |||||||||
| NPI: | 1649517186 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | COLLINS | ||||||||
| FirstName: | STACEY | ||||||||
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| Credential: | PT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 600 OAKMONT LN | ||||||||
| Address2: | STE 600C | ||||||||
| City: | WESTMONT | ||||||||
| State: | IL | ||||||||
| PostalCode: | 605595548 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6305756250 | ||||||||
| FaxNumber: | 6305757450 | ||||||||
| Practice Location | |||||||||
| Address1: | 5300 N ILLINOIS ST | ||||||||
| Address2: | STE. 101 | ||||||||
| City: | FAIRVIEW HEIGHTS | ||||||||
| State: | IL | ||||||||
| PostalCode: | 622083500 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6186249300 | ||||||||
| FaxNumber: | 6186249330 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/03/2013 | ||||||||
| LastUpdateDate: | 07/01/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/01/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 2012034045 | MO | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225100000X | 070018183 | IL | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.