Provider Demographics
NPI:1730236373
Name:DOUGLAS, COLLEEN K (PT)
Entity type:Individual
Prefix:
First Name:COLLEEN
Middle Name:K
Last Name:DOUGLAS
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:225 HOWELLS RD
Mailing Address - Street 2:2ND FLOOR
Mailing Address - City:BAY SHORE
Mailing Address - State:NY
Mailing Address - Zip Code:11706-5319
Mailing Address - Country:US
Mailing Address - Phone:631-665-4560
Mailing Address - Fax:
Practice Address - Street 1:225 HOWELLS RD
Practice Address - Street 2:2ND FLOOR
Practice Address - City:BAY SHORE
Practice Address - State:NY
Practice Address - Zip Code:11706-5319
Practice Address - Country:US
Practice Address - Phone:631-665-4560
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-05
Last Update Date:2010-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY18832-1225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist