Provider Demographics
NPI:1790343283
Name:LIND, COLLEEN NICOLE (DPT)
Entity Type:Individual
Prefix:MRS
First Name:COLLEEN
Middle Name:NICOLE
Last Name:LIND
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:4444 FOREST PARK AVE
Mailing Address - Street 2:CB 8502
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63108-2212
Mailing Address - Country:US
Mailing Address - Phone:314-286-1940
Mailing Address - Fax:314-286-1473
Practice Address - Street 1:4444 FOREST PARK AVE
Practice Address - Street 2:STE 1210
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63108-2212
Practice Address - Country:US
Practice Address - Phone:314-286-1940
Practice Address - Fax:314-286-1473
Is Sole Proprietor?:No
Enumeration Date:2019-05-30
Last Update Date:2021-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2019029984225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO480071652Medicaid