Provider Demographics
NPI:1366088692
Name:SHILLINGLAW, COLIN MARK (ATC, LAT)
Entity type:Individual
Prefix:
First Name:COLIN
Middle Name:MARK
Last Name:SHILLINGLAW
Suffix:
Gender:M
Credentials:ATC, LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10839 CACTUS TRL
Mailing Address - Street 2:
Mailing Address - City:FLINT
Mailing Address - State:TX
Mailing Address - Zip Code:75762-8773
Mailing Address - Country:US
Mailing Address - Phone:254-733-5234
Mailing Address - Fax:
Practice Address - Street 1:1319 EARL CAMPBELL PKWY
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75701-9697
Practice Address - Country:US
Practice Address - Phone:903-262-1000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-21
Last Update Date:2019-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX10392255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic TrainerGroup - Single Specialty