Provider Demographics
NPI:1114384963
Name:MCCOLLEY, KATIE (PTA)
Entity Type:Individual
Prefix:
First Name:KATIE
Middle Name:
Last Name:MCCOLLEY
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9011 59TH AVENUE CIR E
Mailing Address - Street 2:
Mailing Address - City:BRADENTON
Mailing Address - State:FL
Mailing Address - Zip Code:34202-9665
Mailing Address - Country:US
Mailing Address - Phone:570-854-9402
Mailing Address - Fax:
Practice Address - Street 1:9085 TOWN CENTER PKWY
Practice Address - Street 2:
Practice Address - City:LAKEWOOD RANCH
Practice Address - State:FL
Practice Address - Zip Code:34202-4175
Practice Address - Country:US
Practice Address - Phone:919-425-5080
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-01-25
Last Update Date:2016-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPTA23240225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant