Provider Demographics
NPI:1275998783
Name:MCDONELL, COLLIN
Entity type:Individual
Prefix:
First Name:COLLIN
Middle Name:
Last Name:MCDONELL
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14809 BLUE RIDGE CT
Mailing Address - Street 2:
Mailing Address - City:MOORPARK
Mailing Address - State:CA
Mailing Address - Zip Code:93021-5047
Mailing Address - Country:US
Mailing Address - Phone:805-341-7496
Mailing Address - Fax:
Practice Address - Street 1:14809 BLUE RIDGE CT
Practice Address - Street 2:
Practice Address - City:MOORPARK
Practice Address - State:CA
Practice Address - Zip Code:93021-5047
Practice Address - Country:US
Practice Address - Phone:805-341-7496
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-12-28
Last Update Date:2025-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA43330225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist