Provider Demographics
NPI:1467959486
Name:COLLINS, TYREL
Entity Type:Individual
Prefix:
First Name:TYREL
Middle Name:
Last Name:COLLINS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14160 GOODHUE ST NE
Mailing Address - Street 2:
Mailing Address - City:HAM LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:55304-6829
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:600 E MAIN ST
Practice Address - Street 2:
Practice Address - City:ANOKA
Practice Address - State:MN
Practice Address - Zip Code:55303-2527
Practice Address - Country:US
Practice Address - Phone:763-421-3722
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-06
Last Update Date:2018-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist