Basic Information
| Provider Information | |||||||||
| NPI: | 1710182191 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | COLLINS | ||||||||
| FirstName: | MICHELLE | ||||||||
| MiddleName: | SANDY | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | MS, ATC, LAT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4537 ROSEDALE RD | ||||||||
| Address2: | |||||||||
| City: | PORT ALLEN | ||||||||
| State: | LA | ||||||||
| PostalCode: | 707674351 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2252681311 | ||||||||
| FaxNumber: | 2253446836 | ||||||||
| Practice Location | |||||||||
| Address1: | 1 NORTH STADIUM ROAD | ||||||||
| Address2: | LSU-BROUSSARD ATHLETIC TRAINING ROOM | ||||||||
| City: | BATON ROUGE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 70894 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2255782496 | ||||||||
| FaxNumber: | 2255783924 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/18/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2255A2300X | ATH.J00335 | LA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Specialist/Technologist | Athletic Trainer |
No ID Information.