Provider Demographics
NPI:1184963589
Name:COLLEY, HERMAN L III
Entity type:Individual
Prefix:MR
First Name:HERMAN
Middle Name:L
Last Name:COLLEY
Suffix:III
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10098A BEARCREEK RD
Mailing Address - Street 2:
Mailing Address - City:LUCASVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:45648-8622
Mailing Address - Country:US
Mailing Address - Phone:740-259-2351
Mailing Address - Fax:
Practice Address - Street 1:10098A BIG BEARCREEK RD
Practice Address - Street 2:
Practice Address - City:LUCASVILLE
Practice Address - State:OH
Practice Address - Zip Code:45648-8622
Practice Address - Country:US
Practice Address - Phone:740-259-2351
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-02-05
Last Update Date:2013-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH06837225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant