Provider Demographics
NPI:1609646124
Name:CANTWELL, COLIN W
Entity Type:Individual
Prefix:
First Name:COLIN
Middle Name:W
Last Name:CANTWELL
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 1:203 ROCKBROOK DR
Mailing Address - Street 2:
Mailing Address - City:WYLIE
Mailing Address - State:TX
Mailing Address - Zip Code:75098-6140
Mailing Address - Country:US
Mailing Address - Phone:682-224-9431
Mailing Address - Fax:
Practice Address - Street 1:1333 CORPORATE DR STE 330
Practice Address - Street 2:
Practice Address - City:IRVING
Practice Address - State:TX
Practice Address - Zip Code:75038-2583
Practice Address - Country:US
Practice Address - Phone:972-871-1800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-05
Last Update Date:2024-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX212717224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant