Provider Demographics
NPI:1417368010
Name:COLLICO, DARCIE (PT)
Entity Type:Individual
Prefix:
First Name:DARCIE
Middle Name:
Last Name:COLLICO
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1034 S BRENTWOOD BLVD STE 300
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63117-1203
Mailing Address - Country:US
Mailing Address - Phone:314-644-1978
Mailing Address - Fax:314-647-1350
Practice Address - Street 1:700 WEBER RD
Practice Address - Street 2:
Practice Address - City:O FALLON
Practice Address - State:IL
Practice Address - Zip Code:62269-2248
Practice Address - Country:US
Practice Address - Phone:618-624-6000
Practice Address - Fax:618-726-4858
Is Sole Proprietor?:No
Enumeration Date:2014-05-16
Last Update Date:2014-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0700107382251G0304X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251G0304XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGeriatrics