Provider Demographics
NPI:1124261474
Name:MORAN, COLLEEN (PT)
Entity type:Individual
Prefix:
First Name:COLLEEN
Middle Name:
Last Name:MORAN
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 1:823 GATEWAY CENTER WAY
Mailing Address - Street 2:131
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92102-4541
Mailing Address - Country:US
Mailing Address - Phone:619-906-4623
Mailing Address - Fax:619-906-4564
Practice Address - Street 1:75-1029 HENRY ST
Practice Address - Street 2:SUITE 101
Practice Address - City:KAILUA KONA
Practice Address - State:HI
Practice Address - Zip Code:96740-1666
Practice Address - Country:US
Practice Address - Phone:808-334-0806
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-04-16
Last Update Date:2016-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA23819225100000X
HI2988225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist