Provider Demographics
NPI:1508986233
Name:GARY COLLETTO PT
Entity Type:Organization
Organization Name:GARY COLLETTO PT
Other - Org Name:COLLETTO PHYSICAL THERAPY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PT
Authorized Official - Prefix:
Authorized Official - First Name:KATHERINE
Authorized Official - Middle Name:
Authorized Official - Last Name:PRENTICE
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:818-366-3935
Mailing Address - Street 1:16692 KNOLLWOOD DR
Mailing Address - Street 2:
Mailing Address - City:GRANADA HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91344-2621
Mailing Address - Country:US
Mailing Address - Phone:818-366-3935
Mailing Address - Fax:818-368-9351
Practice Address - Street 1:10605 BALBOA BLVD
Practice Address - Street 2:#240
Practice Address - City:GRANADA HILLS
Practice Address - State:CA
Practice Address - Zip Code:91344-6342
Practice Address - Country:US
Practice Address - Phone:818-366-3935
Practice Address - Fax:818-368-9351
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-29
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT7597225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA698117OtherACN GROUP UHC
CAW16102Medicare ID - Type Unspecified