Provider Demographics
NPI:1326385691
Name:HENN, COLLEEN MARIE (PTA)
Entity Type:Individual
Prefix:MISS
First Name:COLLEEN
Middle Name:MARIE
Last Name:HENN
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:MISS
Other - First Name:COLLEEN
Other - Middle Name:MARIE
Other - Last Name:HENN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PTA
Mailing Address - Street 1:2455 UNION BLVD APT 1A
Mailing Address - Street 2:
Mailing Address - City:ISLIP
Mailing Address - State:NY
Mailing Address - Zip Code:11751-3146
Mailing Address - Country:US
Mailing Address - Phone:516-362-7472
Mailing Address - Fax:
Practice Address - Street 1:2455 UNION BLVD APT 1A
Practice Address - Street 2:
Practice Address - City:ISLIP
Practice Address - State:NY
Practice Address - Zip Code:11751-3146
Practice Address - Country:US
Practice Address - Phone:516-362-7472
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-07
Last Update Date:2013-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY005478-1225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant