Provider Demographics
NPI:1124396288
Name:COLLINS, MARY JEANETTE (ATC, LATC)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:JEANETTE
Last Name:COLLINS
Suffix:
Gender:F
Credentials:ATC, LATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:614 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BROOKFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:64628-2341
Mailing Address - Country:US
Mailing Address - Phone:660-734-2083
Mailing Address - Fax:
Practice Address - Street 1:411 CENTRAL METHODIST SQ
Practice Address - Street 2:
Practice Address - City:FAYETTE
Practice Address - State:MO
Practice Address - Zip Code:65248-1104
Practice Address - Country:US
Practice Address - Phone:660-248-6289
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-12-05
Last Update Date:2011-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20100196462255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer