Provider Demographics
NPI:1891510939
Name:COLLINS, AUSTIN CANYON
Entity type:Individual
Prefix:
First Name:AUSTIN
Middle Name:CANYON
Last Name:COLLINS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:700 S MANHATTAN PL APT 627
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90005-4142
Mailing Address - Country:US
Mailing Address - Phone:760-899-2119
Mailing Address - Fax:
Practice Address - Street 1:433 N 4TH ST STE 208
Practice Address - Street 2:
Practice Address - City:MONTEBELLO
Practice Address - State:CA
Practice Address - Zip Code:90640-4309
Practice Address - Country:US
Practice Address - Phone:818-561-7707
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-11-21
Last Update Date:2024-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT307109225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist