Provider Demographics
NPI:1144933110
Name:COLLAZO, SEBASTIAN LUIS (MSOTR/L)
Entity type:Individual
Prefix:
First Name:SEBASTIAN
Middle Name:LUIS
Last Name:COLLAZO
Suffix:
Gender:M
Credentials:MSOTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:465 PARK AVE FL 1
Mailing Address - Street 2:
Mailing Address - City:COLLINGSWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:08108-3076
Mailing Address - Country:US
Mailing Address - Phone:609-477-3351
Mailing Address - Fax:
Practice Address - Street 1:875 ROUTE 73 N STE B
Practice Address - Street 2:
Practice Address - City:MARLTON
Practice Address - State:NJ
Practice Address - Zip Code:08053-1273
Practice Address - Country:US
Practice Address - Phone:856-985-3336
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-04
Last Update Date:2023-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ46TR00803100225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Single Specialty