Provider Demographics
NPI:1487733127
Name:MEDLIN, COLLEEN A
Entity type:Individual
Prefix:
First Name:COLLEEN
Middle Name:A
Last Name:MEDLIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:COLLEEN
Other - Middle Name:
Other - Last Name:MEDLIN PIERCE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PT
Mailing Address - Street 1:4801 DORSEY HALL DR
Mailing Address - Street 2:SUITE 201
Mailing Address - City:ELLICOTT CITY
Mailing Address - State:MD
Mailing Address - Zip Code:21042-7766
Mailing Address - Country:US
Mailing Address - Phone:410-997-5191
Mailing Address - Fax:410-997-7957
Practice Address - Street 1:4801 DORSEY HALL DR
Practice Address - Street 2:SUITE 201
Practice Address - City:ELLICOTT CITY
Practice Address - State:MD
Practice Address - Zip Code:21042-7766
Practice Address - Country:US
Practice Address - Phone:410-997-5191
Practice Address - Fax:410-997-7957
Is Sole Proprietor?:No
Enumeration Date:2006-11-03
Last Update Date:2012-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD20605225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD136987ZANWMedicare PIN