Provider Demographics
NPI:1306503651
Name:COLVIN, BREANNA LEE (DPT)
Entity type:Individual
Prefix:
First Name:BREANNA
Middle Name:LEE
Last Name:COLVIN
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:212 S HENRY ST APT 2
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53703-4434
Mailing Address - Country:US
Mailing Address - Phone:570-620-6135
Mailing Address - Fax:
Practice Address - Street 1:502 S HIGH ST
Practice Address - Street 2:
Practice Address - City:RANDOLPH
Practice Address - State:WI
Practice Address - Zip Code:53956-1499
Practice Address - Country:US
Practice Address - Phone:570-620-6135
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-22
Last Update Date:2021-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist