Provider Demographics
NPI:1528702073
Name:CALVERT, COLIN JOSEPH (MAT, LAT, ATC)
Entity type:Individual
Prefix:
First Name:COLIN
Middle Name:JOSEPH
Last Name:CALVERT
Suffix:
Gender:M
Credentials:MAT, LAT, ATC
Other - Prefix:MR
Other - First Name:COLIN
Other - Middle Name:JOSEPH
Other - Last Name:CALVERT
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MAT, LAT, ATC
Mailing Address - Street 1:3946 ICE WAY
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46805-1018
Mailing Address - Country:US
Mailing Address - Phone:574-440-4252
Mailing Address - Fax:
Practice Address - Street 1:3946 ICE WAY
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46805-1018
Practice Address - Country:US
Practice Address - Phone:574-440-4252
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-21
Last Update Date:2024-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
2255A2300X
IN36003696A2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer