Provider Demographics
NPI:1821770900
Name:COLLINS, SPENCER THOMAS (PTA)
Entity Type:Individual
Prefix:
First Name:SPENCER
Middle Name:THOMAS
Last Name:COLLINS
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2708 SAINT LOUIS RD APT C
Mailing Address - Street 2:
Mailing Address - City:JEFFERSON CITY
Mailing Address - State:MO
Mailing Address - Zip Code:65101-4477
Mailing Address - Country:US
Mailing Address - Phone:314-798-3662
Mailing Address - Fax:
Practice Address - Street 1:3645 COOK AVE
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63113-3801
Practice Address - Country:US
Practice Address - Phone:314-798-3662
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-07
Last Update Date:2023-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2013038749225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant