Provider Demographics
NPI:1588624308
Name:COLVIN, TY C (MS, ATC/L)
Entity Type:Individual
Prefix:MRS
First Name:TY
Middle Name:C
Last Name:COLVIN
Suffix:
Gender:F
Credentials:MS, ATC/L
Other - Prefix:MISS
Other - First Name:TY
Other - Middle Name:C
Other - Last Name:MASON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS, ATC, LAT
Mailing Address - Street 1:530 BRIDGE CREEK BLVD
Mailing Address - Street 2:
Mailing Address - City:OCOEE
Mailing Address - State:FL
Mailing Address - Zip Code:34761-4717
Mailing Address - Country:US
Mailing Address - Phone:321-662-6512
Mailing Address - Fax:
Practice Address - Street 1:530 BRIDGE CREEK BLVD
Practice Address - Street 2:
Practice Address - City:OCOEE
Practice Address - State:FL
Practice Address - Zip Code:34761-4717
Practice Address - Country:US
Practice Address - Phone:321-662-6512
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-24
Last Update Date:2009-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL 26282255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer