Provider Demographics
NPI:1457968844
Name:COLLINS, DYLAN
Entity Type:Individual
Prefix:
First Name:DYLAN
Middle Name:
Last Name:COLLINS
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 1:105 DAWN ST
Mailing Address - Street 2:
Mailing Address - City:WAKE VILLAGE
Mailing Address - State:TX
Mailing Address - Zip Code:75501-5874
Mailing Address - Country:US
Mailing Address - Phone:903-826-7200
Mailing Address - Fax:
Practice Address - Street 1:5610 RICHMOND RD
Practice Address - Street 2:
Practice Address - City:TEXARKANA
Practice Address - State:TX
Practice Address - Zip Code:75503-0500
Practice Address - Country:US
Practice Address - Phone:903-831-4081
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-29
Last Update Date:2020-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2109152225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant