Provider Demographics
NPI:1932271798
Name:COLLETT, ZACHARY DANIEL (MS, ATC, LAT)
Entity Type:Individual
Prefix:MR
First Name:ZACHARY
Middle Name:DANIEL
Last Name:COLLETT
Suffix:
Gender:M
Credentials:MS, ATC, LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:903 SHERYL ST
Mailing Address - Street 2:
Mailing Address - City:TAHLEQUAH
Mailing Address - State:OK
Mailing Address - Zip Code:74464-8021
Mailing Address - Country:US
Mailing Address - Phone:417-848-1741
Mailing Address - Fax:
Practice Address - Street 1:600 N GRAND AVE
Practice Address - Street 2:
Practice Address - City:TAHLEQUAH
Practice Address - State:OK
Practice Address - Zip Code:74464-2301
Practice Address - Country:US
Practice Address - Phone:918-456-5511
Practice Address - Fax:918-458-2339
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK4542255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK454OtherSTATE LICENSURE NUMBER