Provider Demographics
NPI:1124597901
Name:COLLINS, TERYN ANTHONY
Entity Type:Individual
Prefix:
First Name:TERYN
Middle Name:ANTHONY
Last Name:COLLINS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4195 N VIKING WAY STE F&G
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90808-1466
Mailing Address - Country:US
Mailing Address - Phone:562-420-2112
Mailing Address - Fax:818-241-6853
Practice Address - Street 1:4195 N VIKING WAY STE F&G
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90808-1466
Practice Address - Country:US
Practice Address - Phone:562-420-2112
Practice Address - Fax:818-241-6853
Is Sole Proprietor?:No
Enumeration Date:2018-11-21
Last Update Date:2023-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
CA304450225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician