Provider Demographics
NPI:1871015073
Name:LISTON, COLLEEN MICHELLE (MS, OTR/L)
Entity Type:Individual
Prefix:
First Name:COLLEEN
Middle Name:MICHELLE
Last Name:LISTON
Suffix:
Gender:F
Credentials:MS, OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1911 S 17TH ST STE 100
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28401-6663
Mailing Address - Country:US
Mailing Address - Phone:910-313-2111
Mailing Address - Fax:
Practice Address - Street 1:1911 S 17TH ST STE 100
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28401-6663
Practice Address - Country:US
Practice Address - Phone:910-313-2111
Practice Address - Fax:910-313-2111
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-10
Last Update Date:2017-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC10987225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC10987OtherNC BOT LICENSE