Provider Demographics
NPI:1568830719
Name:WALLACE, COLLIN WILLIAM (DPT)
Entity type:Individual
Prefix:
First Name:COLLIN
Middle Name:WILLIAM
Last Name:WALLACE
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3903 NORTHDALE BLVD
Mailing Address - Street 2:STE 111W
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33624-1853
Mailing Address - Country:US
Mailing Address - Phone:813-805-8167
Mailing Address - Fax:844-214-1382
Practice Address - Street 1:2349 SUNSET POINT RD STE 400
Practice Address - Street 2:
Practice Address - City:CLEARWATER
Practice Address - State:FL
Practice Address - Zip Code:33765-1439
Practice Address - Country:US
Practice Address - Phone:970-371-8965
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-04
Last Update Date:2016-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL30787225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist