Provider Demographics
NPI:1649569427
Name:COLLINS, PHILLIP L (LMP)
Entity Type:Individual
Prefix:MR
First Name:PHILLIP
Middle Name:L
Last Name:COLLINS
Suffix:
Gender:M
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2332 N 128TH ST
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98133-7850
Mailing Address - Country:US
Mailing Address - Phone:206-291-4948
Mailing Address - Fax:
Practice Address - Street 1:401 BROADWAY E STE 204
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98102-5081
Practice Address - Country:US
Practice Address - Phone:206-624-3689
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-04-01
Last Update Date:2011-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA 60206261225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist