Provider Demographics
NPI:1457679730
Name:COLLINS, GRANT MICHAEL (PT)
Entity Type:Individual
Prefix:
First Name:GRANT
Middle Name:MICHAEL
Last Name:COLLINS
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2166 NORTH WESTWOOD BLVD
Mailing Address - Street 2:
Mailing Address - City:POPLAR BLUFF
Mailing Address - State:MO
Mailing Address - Zip Code:63901-2440
Mailing Address - Country:US
Mailing Address - Phone:573-712-2696
Mailing Address - Fax:573-712-2991
Practice Address - Street 1:2166 NORTH WESTWOOD BLVD
Practice Address - Street 2:
Practice Address - City:POPLAR BLUFF
Practice Address - State:MO
Practice Address - Zip Code:63901-2440
Practice Address - Country:US
Practice Address - Phone:573-712-2696
Practice Address - Fax:573-712-2991
Is Sole Proprietor?:No
Enumeration Date:2010-05-11
Last Update Date:2014-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2008020468225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1457679730Medicaid
MO156610001Medicare PIN