Provider Demographics
NPI:1245476647
Name:COLLINS, KELLY J (DPT)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:J
Last Name:COLLINS
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:4516 ARROWHEAD RIDGE DR SE
Mailing Address - Street 2:
Mailing Address - City:RIO RANCHO
Mailing Address - State:NM
Mailing Address - Zip Code:87124
Mailing Address - Country:US
Mailing Address - Phone:505-896-4978
Mailing Address - Fax:
Practice Address - Street 1:4516 ARROWHEAD RIDGE DR SE
Practice Address - Street 2:
Practice Address - City:RIO RANCHO
Practice Address - State:NM
Practice Address - Zip Code:87124
Practice Address - Country:US
Practice Address - Phone:505-896-4978
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-01-06
Last Update Date:2012-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM3911225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMNM303373Medicare PIN