Provider Demographics
NPI:1750443909
Name:COLLAR, AMY LUCKHAM (MPT)
Entity Type:Individual
Prefix:MS
First Name:AMY
Middle Name:LUCKHAM
Last Name:COLLAR
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5720 STONERIDGE MALL RD
Mailing Address - Street 2:STE. 390
Mailing Address - City:PLEASANTON
Mailing Address - State:CA
Mailing Address - Zip Code:94588-2828
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5720 STONERIDGE MALL RD
Practice Address - Street 2:SUITE 390,
Practice Address - City:PLEASANTON
Practice Address - State:CA
Practice Address - Zip Code:94588-2828
Practice Address - Country:US
Practice Address - Phone:925-847-5229
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-14
Last Update Date:2021-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT 18735225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist