Provider Demographics
NPI:1336605138
Name:COLLE, STEPHANE
Entity Type:Individual
Prefix:
First Name:STEPHANE
Middle Name:
Last Name:COLLE
Suffix:
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 1:276 RUE DOLBEC
Mailing Address - Street 2:
Mailing Address - City:ST-EUSTACHE
Mailing Address - State:QUBEC
Mailing Address - Zip Code:J7R6N5
Mailing Address - Country:CA
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1121 W A ST APT 8
Practice Address - Street 2:
Practice Address - City:MOSCOW
Practice Address - State:ID
Practice Address - Zip Code:83843-4610
Practice Address - Country:US
Practice Address - Phone:208-310-2412
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-17
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer