Provider Demographics
NPI:1154963445
Name:WOLLENMANN, COLLIN (DPT)
Entity type:Individual
Prefix:
First Name:COLLIN
Middle Name:
Last Name:WOLLENMANN
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1100 SPRUCE ST APT 9
Mailing Address - Street 2:
Mailing Address - City:TERRE HAUTE
Mailing Address - State:IN
Mailing Address - Zip Code:47807-2152
Mailing Address - Country:US
Mailing Address - Phone:812-630-7180
Mailing Address - Fax:
Practice Address - Street 1:1725 N 5TH ST
Practice Address - Street 2:
Practice Address - City:TERRE HAUTE
Practice Address - State:IN
Practice Address - Zip Code:47804-4010
Practice Address - Country:US
Practice Address - Phone:812-242-3005
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-08
Last Update Date:2019-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN05013483A261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy