Provider Demographics
NPI:1346793908
Name:COLLISON, CONNIE (PT, CBIS, MLD/CDT)
Entity Type:Individual
Prefix:MRS
First Name:CONNIE
Middle Name:
Last Name:COLLISON
Suffix:
Gender:F
Credentials:PT, CBIS, MLD/CDT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:105 S RIDGECREST AVE
Mailing Address - Street 2:
Mailing Address - City:NIXA
Mailing Address - State:MO
Mailing Address - Zip Code:65714-7807
Mailing Address - Country:US
Mailing Address - Phone:417-724-3004
Mailing Address - Fax:417-725-7373
Practice Address - Street 1:105 S RIDGECREST AVE
Practice Address - Street 2:
Practice Address - City:NIXA
Practice Address - State:MO
Practice Address - Zip Code:65714-7807
Practice Address - Country:US
Practice Address - Phone:417-724-3004
Practice Address - Fax:417-725-7373
Is Sole Proprietor?:No
Enumeration Date:2016-08-01
Last Update Date:2016-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2000161104225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist