Provider Demographics
NPI:1033557988
Name:COLLETT, RYAN WYATT
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:WYATT
Last Name:COLLETT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:RYAN
Other - Middle Name:
Other - Last Name:WYATT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:114 WYATT CIR
Mailing Address - Street 2:
Mailing Address - City:BATH SPRINGS
Mailing Address - State:TN
Mailing Address - Zip Code:38311-1000
Mailing Address - Country:US
Mailing Address - Phone:731-549-5841
Mailing Address - Fax:
Practice Address - Street 1:524 W MAIN ST
Practice Address - Street 2:
Practice Address - City:DECATURVILLE
Practice Address - State:TN
Practice Address - Zip Code:38329-8101
Practice Address - Country:US
Practice Address - Phone:731-852-3591
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-06-12
Last Update Date:2013-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN4244225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist