Provider Demographics
NPI:1629319801
Name:COLLAZO, MAITE (MASSAGE THERAPIST)
Entity Type:Individual
Prefix:MRS
First Name:MAITE
Middle Name:
Last Name:COLLAZO
Suffix:
Gender:F
Credentials:MASSAGE THERAPIST
Other - Prefix:MRS
Other - First Name:MAITE
Other - Middle Name:
Other - Last Name:COLLAZO
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MASSAGE THERAPIST
Mailing Address - Street 1:29930 W 12 MILE RD
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48334-3983
Mailing Address - Country:US
Mailing Address - Phone:248-851-3700
Mailing Address - Fax:248-851-9475
Practice Address - Street 1:29930 W 12 MILE RD
Practice Address - Street 2:
Practice Address - City:FARMINGTON HILLS
Practice Address - State:MI
Practice Address - Zip Code:48334-3983
Practice Address - Country:US
Practice Address - Phone:248-851-3700
Practice Address - Fax:248-851-9475
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-12
Last Update Date:2013-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist