Provider Demographics
NPI:1093092660
Name:REAUME, COLLYN (AT)
Entity Type:Individual
Prefix:
First Name:COLLYN
Middle Name:
Last Name:REAUME
Suffix:
Gender:M
Credentials:AT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1209 E 5TH ST
Mailing Address - Street 2:
Mailing Address - City:ROYAL OAK
Mailing Address - State:MI
Mailing Address - Zip Code:48067-2903
Mailing Address - Country:US
Mailing Address - Phone:586-604-7819
Mailing Address - Fax:
Practice Address - Street 1:1501 N BEECH DALY RD
Practice Address - Street 2:
Practice Address - City:DEARBORN HEIGHTS
Practice Address - State:MI
Practice Address - Zip Code:48127-3403
Practice Address - Country:US
Practice Address - Phone:586-604-7819
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-10
Last Update Date:2011-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI26010002772255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer