Provider Demographics
NPI:1528669876
Name:MACCOLLAM, ANGELA (PTA)
Entity type:Individual
Prefix:
First Name:ANGELA
Middle Name:
Last Name:MACCOLLAM
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 1:1235 RIO WAY
Mailing Address - Street 2:
Mailing Address - City:VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:92081-6317
Mailing Address - Country:US
Mailing Address - Phone:760-707-9655
Mailing Address - Fax:
Practice Address - Street 1:3861 MISSION AVE STE B25
Practice Address - Street 2:
Practice Address - City:OCEANSIDE
Practice Address - State:CA
Practice Address - Zip Code:92058-1817
Practice Address - Country:US
Practice Address - Phone:760-655-1322
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-03
Last Update Date:2020-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA50786225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant