Provider Demographics
NPI:1639779952
Name:COLLINS, BRADEN M (DPT)
Entity Type:Individual
Prefix:
First Name:BRADEN
Middle Name:M
Last Name:COLLINS
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 SYCAMORE ST APT 237
Mailing Address - Street 2:
Mailing Address - City:TERRE HAUTE
Mailing Address - State:IN
Mailing Address - Zip Code:47807-2634
Mailing Address - Country:US
Mailing Address - Phone:812-584-8592
Mailing Address - Fax:
Practice Address - Street 1:3177 S 3RD PL
Practice Address - Street 2:
Practice Address - City:TERRE HAUTE
Practice Address - State:IN
Practice Address - Zip Code:47802-3785
Practice Address - Country:US
Practice Address - Phone:812-238-3600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-27
Last Update Date:2020-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN05013970A225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist