Provider Demographics
NPI:1821411331
Name:MCCRACKEN, COLLEEN (DPT)
Entity Type:Individual
Prefix:
First Name:COLLEEN
Middle Name:
Last Name:MCCRACKEN
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1912 STONERS MILL DR
Mailing Address - Street 2:
Mailing Address - City:HUNTERTOWN
Mailing Address - State:IN
Mailing Address - Zip Code:46748-9313
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3898 NEW VISION DR
Practice Address - Street 2:BLDG 13, SUITE D
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46845-1718
Practice Address - Country:US
Practice Address - Phone:260-483-1010
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-02-04
Last Update Date:2014-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN05010922A225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist