Provider Demographics
NPI:1144707225
Name:BROWN, COLLEEN A (PTA)
Entity type:Individual
Prefix:
First Name:COLLEEN
Middle Name:A
Last Name:BROWN
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1435 S MAIN CHAPEL WAY UNIT C129
Mailing Address - Street 2:
Mailing Address - City:GAMBRILLS
Mailing Address - State:MD
Mailing Address - Zip Code:21054-1969
Mailing Address - Country:US
Mailing Address - Phone:703-459-3947
Mailing Address - Fax:
Practice Address - Street 1:40 S DUNDALK AVE STE G3
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21222-4209
Practice Address - Country:US
Practice Address - Phone:410-285-0173
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-23
Last Update Date:2018-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDA4944225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant