Provider Demographics
NPI:1669013074
Name:SIMON, COLLEEN M (PT)
Entity Type:Individual
Prefix:
First Name:COLLEEN
Middle Name:M
Last Name:SIMON
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5209 SANDLEWOOD CT
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30068-2887
Mailing Address - Country:US
Mailing Address - Phone:770-643-0868
Mailing Address - Fax:
Practice Address - Street 1:2850 JOHNSON FERRY RD STE 100
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30062-5684
Practice Address - Country:US
Practice Address - Phone:770-643-0868
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-07
Last Update Date:2019-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA6944225100000X, 2251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAPT006944OtherPROFESSIONAL LICENSING (PHYSICAL THERAPY LICENSE)