Provider Demographics
NPI:1700167467
Name:COLLAZO, BLIA (PT)
Entity Type:Individual
Prefix:
First Name:BLIA
Middle Name:
Last Name:COLLAZO
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3212 TUPELO DR
Mailing Address - Street 2:
Mailing Address - City:MERCED
Mailing Address - State:CA
Mailing Address - Zip Code:95348-9351
Mailing Address - Country:US
Mailing Address - Phone:209-357-5121
Mailing Address - Fax:
Practice Address - Street 1:1675 SHAFFER RD
Practice Address - Street 2:
Practice Address - City:ATWATER
Practice Address - State:CA
Practice Address - Zip Code:95301-4456
Practice Address - Country:US
Practice Address - Phone:209-357-5121
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-09-07
Last Update Date:2011-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT 37804225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPT37804OtherPT