Provider Demographics
NPI:1194898825
Name:COLLICA, CAROL ANN (PT)
Entity type:Individual
Prefix:MRS
First Name:CAROL
Middle Name:ANN
Last Name:COLLICA
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 1:483 OLD WALNUT BR
Mailing Address - Street 2:
Mailing Address - City:NORTH AUGUSTA
Mailing Address - State:SC
Mailing Address - Zip Code:29860-8662
Mailing Address - Country:US
Mailing Address - Phone:803-441-8291
Mailing Address - Fax:
Practice Address - Street 1:444 PARK WEST DRIVE
Practice Address - Street 2:
Practice Address - City:GROVETOWN
Practice Address - State:GA
Practice Address - Zip Code:30813
Practice Address - Country:US
Practice Address - Phone:706-868-6543
Practice Address - Fax:706-868-9579
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-17
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT004494225100000X
SC2753225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA617152988AMedicaid