Provider Demographics
NPI:1871844415
Name:COLLINS, PAM
Entity Type:Individual
Prefix:
First Name:PAM
Middle Name:
Last Name:COLLINS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1371 LEO LN
Mailing Address - Street 2:
Mailing Address - City:DE SOTO
Mailing Address - State:IL
Mailing Address - Zip Code:62924-2220
Mailing Address - Country:US
Mailing Address - Phone:618-922-2341
Mailing Address - Fax:
Practice Address - Street 1:1371 LEO LN
Practice Address - Street 2:
Practice Address - City:DE SOTO
Practice Address - State:IL
Practice Address - Zip Code:62924-2220
Practice Address - Country:US
Practice Address - Phone:618-922-2341
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-22
Last Update Date:2012-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist