Provider Demographics
NPI:1194385088
Name:PERRY, COLLEEN (LAT, ATC)
Entity Type:Individual
Prefix:
First Name:COLLEEN
Middle Name:
Last Name:PERRY
Suffix:
Gender:F
Credentials:LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5075 E 52ND ST APT K203
Mailing Address - Street 2:
Mailing Address - City:ODESSA
Mailing Address - State:TX
Mailing Address - Zip Code:79762-5145
Mailing Address - Country:US
Mailing Address - Phone:323-493-2879
Mailing Address - Fax:
Practice Address - Street 1:4901 E UNIVERSITY BLVD
Practice Address - Street 2:
Practice Address - City:ODESSA
Practice Address - State:TX
Practice Address - Zip Code:79762-8122
Practice Address - Country:US
Practice Address - Phone:432-552-2980
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-13
Last Update Date:2019-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAT74092255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer