Provider Demographics
NPI:1457817652
Name:FOX, COLLEENA LEE (LMT)
Entity Type:Individual
Prefix:MRS
First Name:COLLEENA
Middle Name:LEE
Last Name:FOX
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:950 N 1800 EAST RD
Mailing Address - Street 2:
Mailing Address - City:SHELBYVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62565-4219
Mailing Address - Country:US
Mailing Address - Phone:217-460-0931
Mailing Address - Fax:
Practice Address - Street 1:950 N 1800 EAST RD
Practice Address - Street 2:
Practice Address - City:SHELBYVILLE
Practice Address - State:IL
Practice Address - Zip Code:62565-4219
Practice Address - Country:US
Practice Address - Phone:217-460-0931
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-13
Last Update Date:2019-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL227.020955225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty