Provider Demographics
NPI:1871678037
Name:COLLINS, GINA RENEE (MPT)
Entity Type:Individual
Prefix:
First Name:GINA
Middle Name:RENEE
Last Name:COLLINS
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 1:3200 E LOS ANGELES AVE STE 20
Mailing Address - Street 2:
Mailing Address - City:SIMI VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:93065-3971
Mailing Address - Country:US
Mailing Address - Phone:805-581-4266
Mailing Address - Fax:805-581-5049
Practice Address - Street 1:3200 E LOS ANGELES AVE
Practice Address - Street 2:SUITE 20
Practice Address - City:SIMI VALLEY
Practice Address - State:CA
Practice Address - Zip Code:93065-3972
Practice Address - Country:US
Practice Address - Phone:805-581-4266
Practice Address - Fax:805-581-5049
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-26
Last Update Date:2007-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA27129225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAOPT271290OtherBLUE SHIELD ID
CAWPT27129AMedicare ID - Type Unspecified