Provider Demographics
NPI:1508350109
Name:CROSS, COLBY LEE (PTA)
Entity Type:Individual
Prefix:
First Name:COLBY
Middle Name:LEE
Last Name:CROSS
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2170 IRIS LN
Mailing Address - Street 2:
Mailing Address - City:RICKMAN
Mailing Address - State:TN
Mailing Address - Zip Code:38580-2162
Mailing Address - Country:US
Mailing Address - Phone:931-265-7594
Mailing Address - Fax:
Practice Address - Street 1:34 GRACEY ST
Practice Address - Street 2:
Practice Address - City:SPARTA
Practice Address - State:TN
Practice Address - Zip Code:38583-2046
Practice Address - Country:US
Practice Address - Phone:931-836-2211
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-18
Last Update Date:2018-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN6774225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant