Provider Demographics
NPI:1073522355
Name:COLLINS, GREG S (LMP)
Entity Type:Individual
Prefix:
First Name:GREG
Middle Name:S
Last Name:COLLINS
Suffix:
Gender:M
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2420 S UNION AVE
Mailing Address - Street 2:STE 230
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98405-1322
Mailing Address - Country:US
Mailing Address - Phone:253-759-1500
Mailing Address - Fax:253-759-4172
Practice Address - Street 1:2420 S. UNION AVE
Practice Address - Street 2:STE 230
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98405
Practice Address - Country:US
Practice Address - Phone:253-759-1500
Practice Address - Fax:253-759-4172
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-05
Last Update Date:2012-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00012460225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8929924OtherSTATE CRIME VICTIMS
WA247513OtherL&I