Basic Information
| Provider Information | |||||||||
| NPI: | 1083797336 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | COLLEN | ||||||||
| FirstName: | REBECCA | ||||||||
| MiddleName: | PACK | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MA, PCC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1717 HANKINSON RD | ||||||||
| Address2: | |||||||||
| City: | GRANVILLE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 430239701 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7409755700 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 581 HEBRON RD | ||||||||
| Address2: | |||||||||
| City: | HEATH | ||||||||
| State: | OH | ||||||||
| PostalCode: | 430561402 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7405224673 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/23/2006 | ||||||||
| 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 | 101YP2500X | E0007806 | OH | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
No ID Information.