Provider Demographics
NPI:1720335458
Name:OVERSTREET, COLIN JACOB (DPT)
Entity Type:Individual
Prefix:
First Name:COLIN
Middle Name:JACOB
Last Name:OVERSTREET
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1104 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BENTON
Mailing Address - State:IL
Mailing Address - Zip Code:62812-1565
Mailing Address - Country:US
Mailing Address - Phone:618-439-3399
Mailing Address - Fax:618-439-4801
Practice Address - Street 1:1104 W MAIN ST
Practice Address - Street 2:
Practice Address - City:BENTON
Practice Address - State:IL
Practice Address - Zip Code:62812-1565
Practice Address - Country:US
Practice Address - Phone:618-439-3399
Practice Address - Fax:618-439-4801
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-13
Last Update Date:2012-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070.019280225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist